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ISSN 2320-7302eISSN 2393-9834
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D SVolume 3, Issue 2, September 2015
J ournal of Dental Specilities
J Dent Specialities.2015;3(2)
Associate Editor Prof. (Dr.) Anmol S. Kalha
Assistant Editors Prof. (Dr.) Bhuvana Vijay
Dr. Pankaj Kukreja
(Hony.) Brig. Dr. Anil Kohli – IND
Dr. Lt. Gen. Vimal Arora – IND
Dr. V. P. Jalili – IND
Dr. Vinod Sachdev – IND
Dr. T. Samraj – IND
ORAL MEDICINE & RADIOLOGY
Dr. K.S. Ganapathy – IND
Dr. Bharat Mody - IND
Dr. Nagesh K.S – IND
Dr. Babu Mathews – IND
Dr. Sunitha Gupta – IND
Dr. Shailesh Lele – IND
Dr. Sumanth K.N – MYS
PROSTHODONTICS &
IMPLANTOLOGY
Dr. Mahendranadh Reddy – IND
Dr. Swatantra Aggarwal - IND
Dr. Veena Jain – IND
Dr. Ramesh Chowdhary – IND
Dr. Shilpa Shetty – IND
Dr. Meena Aras – IND
Dr. Mohit Kheur – IND
Dr. Arun Garg – USA
PEDODONTICS &
PREVENTIVE DENTISTRY
Dr. Shobha Tandon - IND
Dr. Navneet Grewal – IND
Dr. Vijay Prakash Mathur – IND
Dr. Nikhil Srivastava – IND
Dr. Ashima Goyal – IND
Editor-in-Chief Prof. (Dr.) Hari Parkash
Dr. Mahesh Verma – IND
Dr. Michael Ong Ah Hup – AUS Dr. Puneet Ahuja – IND
Dr. Anil Chandna – IND
Dr. Simrit Malhi – AUS
PUBLIC HEALTH DENTISTRY
Dr. S.S. Hiremath – IND
Dr. K.V.V. Prasad – IND
Dr. Ashwath Narayan – IND
Dr. Aruna D.S - IND
Dr. Ajith Krishnan – IND
Dr. Rajesh G – IND
Dr. Kumar Rajan – IND
Dr. Raman Bedi – GBR
Dr. Jitendra Ariga – KWT
Dr. Shreyas Tikare - SAU
PERIODONTICS & ORAL
IMPLANTOLOGY
Dr. D. S. Mehta - IND
Dr. Dwarakanath – IND
Dr. Srinath Thakur– IND
Dr. Swathi B. Shetty – IND
Dr. Tarun Kumar – IND
Dr. Ray Williams – USA
Dr. Sudhindra Kulkarni – IND
Dr. Praveen Kudva– IND
ORTHODONTICS &
DENTOFACIAL ORTHOPEDICS
Dr. O.P.Kharbanda – IND
Dr. Krishna Nayak – IND
Dr. Ritu Duggal – IND
Dr. Puneet Batra - IND
Dr. Keluskar M – IND
Dr. Nandini Kamath – IND
Dr. Derek Mahony – AUS
Editorial Manager Prof. (Dr.) Sharad Gupta
Editorial Support Dr. Ipseeta Menon
Dr. Manisha Lakhanpal
Dr. Bhavna Jha
Dr. Siddharth Bansal
Dr. Akshay Bhargava – IND
Dr. Devi Charan Shetty – IND
Dr. Alka Kale – IND
Dr. Vidya Dodwad – IND
Dr. Mohammad Abdul Baseer - KSA
ORAL & MAXILLOFACIAL
SURGERY
Dr. Gopal Krishnan – IND
Dr. Sanjeev Kumar - IND
Dr. Pankaj Sharma – IND
Dr. Vishal Bansal – IND
Dr. Vivek Vardhana Reddy – IND
Dr. Samiran Ghosh – IND
Dr. Indraneel Bhattacharya – USA
CONSERVATIVE &
ENDODONTICS
Dr. Anil Chandra – IND
Dr. Gopikrishna – IND
Dr. Sonali Taneja - IND
Dr. Vimal Sikri – IND
Dr. B. Suresh Chandra – IND
Dr. Vivek Hegde – IND
ORAL & MAXILLOFACIAL
PATHOLOGY &
MICROBIOLOGY
Dr. Ashith Acharya – IND
Dr. Gadiputi Shreedhar – IND
Dr. Simarpreet Virk Sandhu – IND
Dr. Vishnudas Prabhu – IND
Dr. Ajit Singh Rathore – IND
ADVISORY BOARD
EDITORIAL BOARD
Dr. R.P. Chadha has printed the Journal of Dental Specialities in association with Innovative Publications, H-2/94,Bengali Colony, Mahavir
enclave, Part-1, New Delhi-45, Official publication of I.T.S Centre for Dental Specialities and Research, Muradnagar, Ghaziabad(Uttar
Pradesh) owned by Durga Charitable Society.
Editor: Dr. Hari Parkash.
EDITORIAL REVIEW BOARD
J Dent Specialities.2015;3(2) i
CONTENTS
EDITORIAL
Zirconia: The new technological marvel in dentistry Prof. (Dr.) Hari Parkash
GUEST EDITORIAL
What would the martian say?? Where we are with evidence based dentistry today? Prof. Anmol S Kalha osre
ORIGINAL RESEARCH
Alterations in plasma lipid profile patterns in leukoplakia and oral submucous
fibrosis - a pilot study Baduni A, Mody BM, Bagewadi S, Sharma ML, Vijay B, Garg A
Artificial neural network (ANN) modeling and analysis for the prediction of change
in the lip curvature following extraction and non-extraction orthodontic treatment Nanda SB, Kalha AS, Jena AK, Bhatia V, Mishra S
Detection of apoptosis in human periodontal ligament during orthodontic tooth
movement Duggal R, Singh N
Assessment of 4% ocimum sanctum and 0.2% chlorhexidine irrigation as an adjunct to
scaling & root planing in management of chronic periodontitis - a randomized
controlled trial Gaur J, Chandra J, Chaudhry S, Vaish S, Dodwad V
Effect of resilient liner on masticatory efficiency and general patient satisfaction in
completely edentulous patients Mangtani N, Pillai RS, Dinesh Babu B, Jain V
Computed tomography scan evaluation of adequacy for reduction of zygomatic arch
fracture using Gillie’s temporal approach Sonone RM, Kumar S, Kukreja P, Agarwal A, Bhatnagar A, Chhabra V
Risk of bleeding in patients with cardiovascular disease on aspirin undergoing tooth
extraction Mangalgi A, Aftab A, Mathpathi S, Tenglikar P, Devani S, Ingleshwar N
Comparative analysis of post operative analgesic requirement in patients undergoing
minor oral surgery using buprenorphine with lignocaine versus lignocaine - a double
blind study Thukral H, Singh S, Aggrawal A, Kumar S, Mishra V, Anand KR
Assessment of collagen and elastic fibres in various stages of oral submucous fibrosis
using Masson's trichrome, Verhoeff vangieson and picrosirius staining under
light and polarizing microscopy Mishra NSS, Wanjari SP, Parwani RN, Wanjari PV, Kaothalker SP
INVITED REVIEW
Bacterial colonization at implant – abutment interface: a systematic review Lakha T, Kheur M, Kheur S, Sandhu R
123-124
125
126-129
130-139
140-145
146-149
150-155
156-158
159-163
164-169
170-175
176-179
ISSN 2320 – 7302 eISSN 2393 – 9834
J Dent Specialities.2015;3(2) ii
CASE REPORT
Revascularization of a necrotic, infected, immature permanent molar with apical
periodontitis: a case report Vashisth P, Vatsala V, Naik S, Singh MG
Incidental finding of dentigerous cyst - a case report Sushma P, Sowbhagya M.B, Balaji P, Mahesh Kumar T.S
Management of root resorption in maxillary first molar- radectomy Singh A, Aeran H, Dixit S, Arora S, Chaoudhary A
Occlusal guiding flange prosthesis for management of hemimandibulectomy - a case
report Pathak S, Deol S, Jayna A
Odontogenic keratocyst of the angle and ramus of the mandible - a case report Garg S, Sunil MK, Trivedi A, Singla N
Over denture using access post system: an alternative solution for increasing retention SivaKumar V, Hallikerimath RB, Patil A, Sethi M
Total mandibulectomy in a patient with verrucous carcinoma turning into squamous
cell carcinoma of the oral cavity: a rare case report Bande CR, Mohale D, Thakur M, Lambade P
Platelet rich fibrin: a panacea for lost interdental papilla Aspalli S, Nagappa G, Jain AS
Creating smiles- the holistic way!! – orthodontic- surgical correction of bimaxillary
protrusion Shetty A, Basu P, Bhaskar V, Nayak USK
Bonded ceramic inlays or full coverage crowns? – a review and case report Patankar A, Sandhu RK, Sandhu R, Kheur M
GUIDELINES FOR AUTHOR
CONTRIBUTOR’S FORM
LIST OF DENTAL EVENTS
180-182
183-187
188-191
192-194
195-198
199-201
202-206
207-210
211-216
217-219
____________________________________________________________________________Editorial
J Dent Specialities.2015;3(2):123-124 123
Zirconia: The new technological
marvel in dentistry
Prof. (Dr.) Hari Parkash
Editor-in-Chief
The last decade has witnessed a revolution in milled
technology – CAD CAM. This technological marvel
has given a boost to a Metal free milled ceramic
restorations. Amongst these the most successful have
been Zirconia Ceramics.
The term Zirconia is derived from two Persian words:
zar meaning gold and gun meaning colour. This
material was discovered by German chemist Martin
Heinrich Klaproth in 1789. This material does not
occur in Free State naturally but is found in as silicate
oxides or free oxides. A very interesting phenomenon
with this material is its transformation toughening.
This material has three forms i.e., cubic phase which
is stable above 23700C with moderate mechanical
advantage, tetragonal phase which exists between
11700C - 23700C with improved mechanical
properties and a monoclinic phase that exists at room
temperatures to 11700C with reduced mechanical
properties.1 Currently, Zirconia being used in
dentistry is Partially Stabilized Zirconia to which –
mol% of yttria (or CaO/ MgO) has been added. This
allows for small tetragonal grains to exist at room
temperatures. Under great stresses, if a crack
propagates through this material, there is a phase
transformation from tetragonal to monoclinic which
is associated with a volumetric expansion of -5%
which stops the crack propagation.
The dental fraternity has accepted Zirconia ceramics
with a very positive note. From single crown,
multiple unit bridges, inlays, onlays, partial veneer
crowns, its use have expanded to endodontic posts,
implants, implant abutments, orthodontic brackets
etc. Various design modifications have also emerged
like monolith crowns for posterior areas, Brux Zir
crowns for patients with parafunctional activities,
high translucency zirconia and super high
translucency zirconia for enhanced esthetics.
On the technical forefront, research shows that
porcelain veneering can be mislaid at the gingival
surface of the connectors to increase their surface
area and strength. Estimation according to Fatigue
parameters indicate that connector area should be
5.7mm2, 12.6mm2 and 18.8mm2 for fabrication of
crown or long span FPD respectively.2 Looking at the
technical complications of this material it can be
concluded that these zirconia restorations in the long
Zirconia: The New Technological Marvel in Dentistry _________________________________________Hari Prakash
J Dent Specialities.2015;3(2):123-124 124
run are comparable to metal ceramic restorations and
can withstand long term functional forces. One of the
most common complications reported are chipping of
veneered ceramic, followed by fracture of core and
debonding of the restoration.
As compared to glass ceramics, zirconia prosthesis
has a reduced translucency. This translucency of
zirconia material is determined by impurities and
structural defects. To increase this translucency the
effects of impurities and structural defects have to be
reduced. The translucency of zirconia material is
reduced by different refractory index and segregation
nature of the alumina which is added into zirconia for
aging stability.3 In few new age Zirconia, the alumina
content is reduced to 0.1 wt% and distribution is
improved. This has led to emergence of super high
translucent zirconia.
It can be summarized that zirconia technology is
among the most recent technological advances
witnessed in the CAD/CAM industry. Its use has
revolutionized the field of dentistry and has
unleashed tremendous potential due to its varied
applications. Evidence based results are pouring in
and the field of Zirconia is constantly improving &
improvising itself for more predictable results.
Research is going on in this field in the areas of
aging, veneering, framework designing, bonding and
repair kit.
REFERENCES 1. Piconi C, Maccauro G. Zirconia as a ceramic
biomaterial. Biomaterials. 1999;20:1-25.
2. Studart AR, Filser F, Kocher P, Gauckler LJ. Fatigue
of zirconia under cyclic loading in water and its
implications for the design of dental bridges. Dent
Mater. 2007;23:106-14.
3. Dittmann R, Urban M., Schechner, G., Hauptmann
H,Mecher, E. Wear behavior of a new zirconia after
hydrothermal accelerated aging. J Dent Res. 2012;
91:1317.
______________________________________________________________________Guest Editorial
J Dent Specialities.2015;3(2):125 125
What would the martian say??
Where we are with evidence based dentistry today?
Prof. Anmol S Kalha osre
BSc BDS MDS Cert Lingual Ortho (Germany)
Col (Retd) AD Corps
Director - PG studies, Senior Professor and Consultant, Orthodontics, I.T.S. Dental College, Greater NOIDA
Prof Kevin O’Brien from the University of
Manchester writes a popular blog and uses this
curious incident of the Martian to under scribe some
very important points in clinical, research and
evidence based outcome domain. This the way it
goes, a little green man from planet Mars lands on
earth and wanders into a convention of dentists. The
dentists are surprised and they ask him who is he?
And what is the purpose of his visit? He replies that
he is from planet Mars and he visits earth as a part of
their mission to discover the universe. In return he
asks them who are you? The Dentist spokesperson
says,” We are dentists”. The Martian asks, “what do
you do? “, The dentists say, “we fix teeth, make
people smile, look good, improve their health and
several other good things”. The Martian says: Prove
it. While the profession has spoken about this long
enough, it is obvious that the only answers to the
Martian would come from evidence and filtering
information for knowledge. For a long time the
profession has been unaccountable, relying on the
existing image of the healing profession that we do
good and patients need to accept it. This notion is
being challenged as awareness grows, patients being
entitled to more information, healthcare policy
planners need structured information to look at
funding services and facilities. Evidence is what is
needed both in clinical practice and research.
Clinical research aims at establishing cause, relating
cause and effect, and looking at therapeutic
outcomes. Clinical research still broadly falls into
Randomized and non Randomized studies. Non
Randomized studies fall into observational studies.
Randomized clinical trials are the gold standard for
assessing the efficiency and safety of interventions.
The controversy that arises today is that all studies in
Dentistry may not be randomized. It is not possible to
have a control group being denied treatment ethically
just to study the effect of an intervention. So there is
a role for non randomized observational studies to be
interpreted and used for clinical decision making and
research. Herein lies the difference between evidence
based dentistry and evidence based medicine. In
medicine 2 different interventions or even a placebo
may be in the larger good of the patient. Dental issues
are more definitive, they need a precise intervention.
A conceptual approach to assessing validity of a trial
needs to be learnt and taught. Is the study population
different from the population to which we wish to
apply the findings? Are the target population
characteristics likely to influence the results? Are the
results generalizable to the target population not
meeting all eligibility criteria?
The debate surrounding the randomized and non
randomized studies has been furthered by flaws in
both designs published in literature. Is there an
agreement between nonrandomized and randomized
trials? No publication answers this. But yet to answer
the questions raised by the Martian, we need to teach
critical appraisal skills so that both studies,
randomized and nonrandomized can be used in
research and decision making without competing
with each other.
____________________________________________________________________Original Research
J Dent Specialities.2015;3(2):126-129 126
Alterations in plasma lipid profile patterns in leukoplakia and oral
submucous fibrosis - a pilot study
Apala Baduni1, Bharat M. Mody2, Shivanand Bagewadi3, Manisha Lakhanpal Sharma4, Bhuvana Vijay5, Aanchal Garg6
ABSTRACT Introduction: Oral submucous fibrosis and leukoplakia are highly prevalent in India
Lipids are the chief cell membrane components which are essential for various biological
functions like cell growth and division of normal as well as malignant tissues. Lipids can
be helpful for studying the variation in the cholesterol levels for diagnosing and treating
the diseases.
Aim: The present study evaluated the plasma lipid profiles in patients with Oral
submucous fibrosis and leukoplakia and controls.
Methodology: 21 patients were selected for the study out of which 7 had OSMF 7 had
oral leukoplakia and 7 were included in control group. Patients with cardiovascular
diseases, uncontrolled diabetes, acute hepatitis, thyroid dysfunction, and any drug history
were excluded from the study. 5ml blood sample was taken and the serum was tested for
triglycride levels(TG) , total cholesterol (TC), LDL, HDL, LDL VLDL level were
analyzed using triglycerides were analyzed by auto-analyzer used for the analysis of the
results is a fully automated biochemistry analyzer.
Results: In this study TC, HDL, LDL level analysis showed lower levels in oral
leukoplakia and OSMF patients than that of the controls.
Conclusion: The alterations in the plasma lipid profile patterns were considerable and
recommend a still in-depth study with larger sample size in this aspect for early diagnosis
and management of oral leukoplakia to prevent malignant transformation.
Keywords: Lipids, Cholesterol, Triglycerides, Leukoplakia, Oral submucous fibrosis.
INTRODUCTION
ipids are the chief cell membrane components
which are essential for various biological
functions like cell growth and division of normal as
well as malignant tissues. Lipids can be helpful for
studying the variation in the cholesterol levels for
diagnosing and treating the diseases.1,2 Changes in
circulatory levels cholesterol has been associated in
the etiology of colorectal as well as breast cancer.2,3
Using tobacco is an important etiologic factor which
aids in the development of oral precancerous lesions /
conditions and head and neck cancer.4 The
carcinogens present in tobacco stimulate free radicals
and reactive oxygen species (ROS) generation, which
further cause increase in the rate of oxidation /
peroxidation of polyunsaturated fatty acids. This
peroxidation will further release peroxide radicals.
This affects essential components of the cell
membrane and can be involved in tumorigenesis.5
Lipid peroxidation, will increase the consumption of
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DOI: 10.5958/2393-9834.2015.00001.7
lipids which includes total cholesterol, triglycerides
and lipoproteins for generation of new membrane.
Cells carry out these requirements either via
circulation, by the production through the metabolism
or from the degradation of major lipoprotein fractions
like VLDL, LDL or HDL. Reports have shown that
antioxidant vitamins have protective effects against
lipid peroxidation.6,7
Hence the present study was aimed to evaluate the
plasma lipid profile including: (i) total
cholesterol(TC) (ii) LDL cholesterol (LDLC), (iii)
HDL cholesterol (HDLC), (iv) VLDL cholesterol
(VLDLC) and (v) triglycerides(TG) patients with
oral submucous fibrosis OSMF , leukoplakia and
healthy controls.
METHODOLOGY
A study was conducted in the Department of Oral
Medicine and Radiology of I.T.S.-C.D.S.R., Dental
College, Muradnagar. A total of 21 patients were
taken from those visiting the department in the
months of May – June, 2014. Patients were selected
after taking a thorough history and on the basis of
clinical examination by a trained oral medicine and
radiology faculty. Patients with cardiovascular
diseases, uncontrolled diabetes, acute hepatitis,
thyroid dysfunction, and any drug history were
excluded from the study.
Ethical clearance obtained from the institutional
ethical committee. Patients were then divided into 3
1PG student, 2Professor and Head of Department, 3Professor, 4Associate Professor, 5Professor, 6PG student,
Department of Oral Medicine and
Radiology, ITS-CDSR, Muradnagar
Address for Correspondence: Dr Apala Baduni
PG student, Department of Oral
Medicine and Radiology, ITS-CDSR, Muradnagar
Email: [email protected]
Received: 28/01/2015
Accepted: 19/02/2015
L
Alterations in plasma lipid profile patterns in leukoplakia and oral submucous fibrosis - a pilot study ______________________________________________________Baduni A et al.
J Dent Specialities.2015;3(2):126-129 127
groups, Three groups were leukoplakia, OSMF and
healthy controls each group had 7 patients. Patients
were informed prior to the study and a written
consent form was obtained. All 7 patients with
leukoplakia underwent biopsy however only 5
patients with OSMF underwent biopsy. Patients with
OSMF are classified on the basis of Khanna et al.
After confirmed biopsy report patients were recalled
again empty stomach in the morning and 5ml of
blood was collected from each patient and was
allowed to clot. The serum was separated by
centrifugation. Auto-analyzer was used for the
analysis of the results. It is a fully automated
biochemistry analyzer. After that the lipid profile
assay of the specific parameters like HDL, LDL,
VLDL, Total cholesterol, Triglycerides were made.
RESULTS
Patients age group ranged from 19- 50 years. Habit of
tobacco consumption in one or the other form
(smoking/chewing/snuff) was present in all the cases.
Out of 21 patients 20 patients were male and one
patient with OSMF was female. In the leukplakia
group out of 7 patients 5 had moderate dysplasia and
2 patients had mild dysplasia. In OSMF group out of
5 patients who underwent biopsy 1 had moderately
advanced and 4 had Early OSMF. Other 2 patients
had grade III OSMF according to Khanna et al
classification.
Table – 1: Mean of TG, TC, HDL, LD in all the
patients of leukoplakia, OSMF, and healthy
controls LEUKOPLAKIA
(mean)
OSMF
(mean)
CONTROL
(mean)
TG 126.14 134.85 143.14
TC 114.42 128.57 157.85
HDL 22.85 33.71 42
LDL 35.14 50.14 82.42
VLDL 17.28 26.71 31
Table - 2: Histopathological stages of dyspalsia12
Stages of
dysplasia
Features
Squamous
hyperplasia
This may be in the spinous layer
(acanthosis) and/or in the
basal/parabasal cell layers (basal cell
hyperplasia); the architecture shows
regular stratification without cellular
atypia
Mild dysplasia The architectural disturbance is
limited to the lower third of the
epithelium accompanied by
cytological atypia
Moderate
dysplasia
The architectural disturbance extends
into the middle third of the
epithelium; consideration of the
degree of cytological atypia may
require upgrading
Severe dysplasia The architectural disturbance involves
more than two thirds of the
epithelium; architectural disturbance
into the middle third of the epithelium
with sufficient cytologic atypia is
upgraded from moderate to severe
dysplasia
Carcinoma in situ Full thickness or almost full thickness
architectural disturbance in the viable
cell layers accompanied by
pronounced cytological atypia
DISCUSSION Oral submucous fibrosis (OSMF) is a chronic disease
of the oral cavity, characterized by an epithelial and
subepithelial inflammatory reaction followed by
fibroelastic changes in the submucosa.8 Oral
submucous fibrosis has high occurrence in India.
Most of the OSMF cases in this study were in their
second and third decades with a male predominance.
All the cases of OSMF consumed areca nut in some
form. OSMF is considered a disease of multi factorial
etiology and various theories have been proposed.9
Excessive use of areca nut may cause fibrosis due to
increased synthesis of collagen and induce the
production of free radicals and reactive oxygen
species, which are responsible for high rate of
oxidation/peroxidation of polyunsaturated fatty acids
which affect essential constituents of cell membrane
and might be involved in tumorigenesis.10
Leukoplakia is the most common premalignant or
potentially malignant lesion of the oral mucosa.11
Leukoplakia is at present defined as ‘‘A white plaque
of questionable risk having excluded (other) known
diseases or disorders that carry no increased risk for
cancer”.12
On histopathological basis, difference can be seen in
dysplastic and non-dysplastic leukoplakia. Dysplasia
can be assessed on the basis of architectural
disturbance with cytological atypia. In 2005 WHO
classified dysplasia in 5 stages. (Table 2).12 It is
supposed that tobacco carcinogens can stimulate
production of free radicals as well as reactive oxygen
species, which are accountable for the increased rate
of oxidation/ peroxidation of polyunsaturated fatty
acids. Release of peroxide radicals is promoted by
this peroxidation which leads to increased
consumption of lipids.5
This affects important components of the cell
membrane and might be involved in carcinogenesis /
tumorigenesis.13 Animal studies have shown that
nicotine, which is a tobacco carcinogen, affects the
activity of enzymes responsible for lipid
metabolism.14
Newly forming and fast proliferating malignant cells
need many basic components such as lipids well
above the normal physiological limits leading to
diminished lipid stores.15,16 Lipid peroxidation can
also develop lipid peroxidation product,
Alterations in plasma lipid profile patterns in leukoplakia and oral submucous fibrosis - a pilot study ______________________________________________________Baduni A et al.
J Dent Specialities.2015;3(2):126-129 128
malondialdehyde, which cross-links with
deoxyribonucleic acid (DNA) on the same as well as
opposite strands via adenine and cytosine. This can
contribute to carcinogenecity and mutagenecity in
mammalian cells. 17
The inverse relation was observed between the total
cholesterol and disease stage and mortality in various
malignancies.15 In 1999 Rywik SL et al had shown a
relatively high risk of cancer mortality with a
significant lower total cholesterol and HDL. Lower
level of TC was recommended due to increased
consumption by tumor cells.16
Lower level was observed in plasma HDL in Oral
leukoplakia and OSMF than controls were present in
the study. This finding is in accordance with earlier
reports, that low HDL levels is an additional
predictor of cancer. Patel et al also reported that low
levels of HDL may be a consequence of disease that
is mediated by utilization of cholesterol for
membrane biogenesis.18 Jacqueline et al observed a
lower HDL in widespread disease than with localized
tumors.17
The range of LDL in oral leukoplakia and OSMF
patients was respectively lower than the controls.
Patel et al did not observe low levels of LDL in head
and neck malignancies.18
Rose et al reported 66% higher mortality rate due to
cancer in the group of cancer patients with lowest
plasma cholesterol than in the highest plasma
cholesterol.19 The low plasma lipid status of the
patient may be a positive indicator for initial changes
occurring in neoplastic cells.
Neufeld et al have reported passive smoking as a
significant risk factor for decreased HDLC.20 In this
study TC, HDL, LDL level analysis showed lower
levels in oral leukoplakia and OSMF patients than
that of the controls. Less difference was present in
triglycerides and VLDL levels was observed in
leukoplakia and OSMF patients than the control
group. Our results have been in accordance to the
previous studies that have been conducted
before.21,22,23 There was much more decrease in all
the parameters in leukoplakia as compared to OSMF
that can be due to the fact that most of the patients
suffering from leukoplakia showed more dysplastic
changes as compared to the OSMF patients who
mostly showed early changes.24,25 As it was a pilot
study small sample size was taken. Tissue level lipid
analysis should be done in further studies tissue to
determine uptake of lipid by the altered tissue and
comparision with oral cancer is also suggested for
further studies
In conclusion TC, HDL, LDL level analysis showed
lower levels in oral leukoplakia and OSMF patients
than that of the controls. Less difference was present
in triglycerides and VLDL levels was observed in
leukoplakia and OSMF patients than the control
group. Study with larger sample size should be done
in this aspect for early diagnosis and management of
oral leukoplakia and OSMF.
REFERENCES 1. Schatzkin A, Hoover RN, Taylor PR, Ziegler
RG, Carter CL, Albanes D, Larson DB, Licitra LM.
Site-specific analysis of total serum cholesterol and
incident cancers in the National Health and Nutrition
Examination Survey I epidemiologic follow-up study.
Cancer Res. 1988;48:452-58.
2. Forones NM, Falcan JB, Mattos D, Barone B.
Cholesterolemia incolorectal cancer.
Hepatogastroenterology. 1998;45:1531-34.
3. Chyou PH, Nomura AM, Stemmermann GN, Kato I.
Prospective study of serum cholesterol and site-
specific cancers. J Clin Epidemiol.1992;45:287-92.
4. Poorey V, Thakur P. Alteration of lipid profile in
patients with head and neck malignancy. Ind J
Otolaryng Head Neck Surg. 2015 DOI
10.1007/s12070-015-089-4.
5. Ames BN. Dietary carcinogens and anticarcinogens:
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How to cite this article: Baduni A, Mody BM, Bagewadi S, Sharma ML, Vijay B, Garg A. Alterations in plasma lipid profile
patterns in leukoplakia and oral submucous fibrosis - a pilot study.
J Dent Specialities 2015;3(2):126-129.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
____________________________________________________________________Original Research
J Dent Specialities.2015;3(2):130-139 130
Artificial neural network (ANN) modeling and analysis for the
prediction of change in the lip curvature following extraction
and non-extraction orthodontic treatment
Smruti Bhusan Nanda1, Anmol S Kalha2, Ashok Kumar Jena3, Virag Bhatia4, Sumita Mishra5
ABSTRACT Objective: To establish and determine the accuracy of ANN model for the analysis of
lip curve change following extraction and non-extraction orthodontic treatment.
Methods: Forty adult subjects who required various combinations of premolars
extraction and non-extraction for the correction of their malocclusion were chosen.
Based on the extraction pattern, all the subjects (n=40) were divided equally into an
extraction and a non-extraction group. The effect of extraction and non-extraction
treatment on the depth of upper and lower lip curvature was measured on the lateral
cephalograms recorded in natural head position. The data obtained from the
cephalometric analysis were used to produce a trained ANN model and then the model
was analyzed to determine its accuracy in the prediction of upper and lower lip
curvature change.
Results: The mean change in the depth of upper lip curvature following various
combinations of premolars extraction and non-extraction treatment was significantly
different (P<0.05). The predicted values of upper and lower lip curvature change by
ANN model were very close to the actual regression analysis values. However, the
mean error in predicting the change in the upper and lower lip curvature by ANN model
analysis was only 29.6% and 7% respectively which was much less as compared to the
routine regression analysis.
Conclusions: The premolars extraction and non-extraction orthodontic treatment had
significant effect on the depth of upper lip curve, and the mean error in predicting the
change in lip curvature with ANN analysis was much less as compared to computer
based statistical analysis.
Key words: Lip curvature changes, Extraction and non-extraction treatment, Artificial
neural network analysis.
INTRODUCTION
valuation of the human facial profile has always
been an essential part of orthodontic diagnosis
and treatment planning.1 Successful evaluation of
facial balance and harmony includes a study of the
facial soft tissue characteristic. Thus the relationships
of nose, lips and chin are important considerations.
However, significant consideration has been given to
the actual depth of curvature of the lips and the
importance of these curves to the overall perception
of the lateral facial profile.2,3 The presence of varying
inherent internal soft tissue architecture, however,
has complicated the attempts at predicting soft tissue
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DOI: 10.5958/2393-9834.2015.00002.9
responses to treatment.3 Consequently, ratios of lip
to incisor retraction have gained only limited
acceptance because it has been recognized that the
interactions that might determine soft tissue changes
are complex.4
Currently many multiple-factor analysis methods are
available for medical use and among these artificial
neural network (ANN) model analysis is very
commonly used. ANN is basically an information
processing paradigm inspired by biological nervous
systems in human brain. The ANN is made up of
large number of highly interconnected processing
elements called neurons.5 In true sense artificial
neural networks are the simple clustering of the
primitive artificial neurons and this clustering occurs
by creating layers, which are then connected to one
another. As shown in Fig.1, the input layer consists
of neurons that receive input from the external
environment. The output layer consists of neurons
that communicate the output of the system to the user
or external environment. There are usually a number
of hidden layers between these input and output
1Reader, 5Senior Lecturer, Department of Orthodontics,
Institute of Dental Sciences, SOA
University, Bhubaneswar, Odisha, India. 2Director, Professor and Head, ITS
Greater Noida, A 103 Gulmohar Garden, Sector 44, NOIDA, NCR. 3Assistant Professor,
Unit of Orthodontics, Department of Dental Surgery,
All India Institute of Medical Sciences,
Sijua, Dumduma, Bhubaneswar, Odisha, India. 4Reader, Department of Orthodontics,
Modern Dental College and Research Center, Gandhi Nagar, Airport Road,
Indore, India.
Address for Correspondence:
Dr. Smruti Bhusan Nanda
Reader Department of Orthodontics
Institute of Dental Sciences,
SOA University Bhubaneswar, Odisha, India.
Email: [email protected]
Received: 17/02/2015
Accepted: 18/06/2015
E
Artificial neural network (ANN) modeling and analysis for the prediction of change in the lip curvature following extraction and non-extraction orthodontic treatment __________________Nanda SB et al.
J Dent Specialities.2015;3(2):130-139 131
layers. However, the Fig.1 is a simple structure with
only one hidden layer. When the input layer receives
the input, its neurons produce output and this
becomes input to the other layers of the system. The
process continues until a certain condition is satisfied
or until the output layer is invoked and fires their
output to the external environment. The human brain
learns from experience. However, neural networks
are called machine learning algorithms, because
changing of its connection weights (W in Fig.2)
causes the network to learn the solution to a problem.
The strength of connection between the neurons is
stored as a weight-value for the specific connection.
The system learns new knowledge by adjusting these
connection weights. The learning ability of a neural
network is determined by its architecture and by the
algorithmic method chosen for training. The ANN
models are particularly beneficial when one is
searching various problems because of their ability to
process complicated problems of uncertainty,
nonconfiguration, nonlinearity and multiple factor
interactions. As a result, the application of ANN
shows great potential as a support system and
management system in medical decision making. In
orthodontics, ANN models have only been used for
human craniofacial growth classification6, prediction
of anterior temporal muscle activity7 and deciding the
need of extractions prior to orthodontic treatment.8
However, the present study was designed to
determine the accuracy of ANN model analysis for
the prediction of lip curvature change following
extraction and non-extraction orthodontic treatment.
MATERIALS AND METHODS
Total 40 adult subjects who required either all first
premolars or upper first and lower second premolars
or all second premolars extraction or without any
tooth extraction for the correction of their
malocclusion were included in the study. Prior to the
commencement of the trial, all the participants were
informed and a written consent was obtained. The
study was also approved by the Ethical Committee.
All the 40 subjects were treated by using consistent
contemporary biomechanical principles and this
study was done over a period of seventeen months.
The subjects were divided into 2 main groups of each
containing 20 subjects i.e. Group-I [Non-extraction
group] and Group-II [Extraction group; all first
premolars (n=8), upper first and lower second
premolars (n=6), all second premolars (n=6)]. The
mean age of the subjects at the beginning of study in
the extraction group was 19 year 9 months and in the
non-extraction group was 18 year 9 months.
Pretreatment and post-treatment lateral cephalograms
recorded in the natural head position were analyzed
by the same investigator (SBN) to determine the
upper and lower lip curvature change. All the
cephalograms were recorded in the same machine
with similar exposure parameters. In order to provide
a consistent reference plane for evaluating horizontal
changes in landmarks, both sphenoethmoid (Se) and
the inferior pterygomaxillary point (Ptm) on the
pterygomaxillary vertical (PMV) line were
transferred from the pretreatment tracing to post-
treatment tracing, by superimposing on the cranial
base landmarks of the pretreatment radiographs as
described by Bjork and Skieller.9 Landmarks chosen
for the study were based on the definitions of Nanda
et al.10 Linear measurements were multiplied by a
factor of 0.9 to take into account the 9% enlargement
factor. In order to access the effect of extraction and
non-extraction treatment on soft tissue, the depths of
upper and lower lip curves were measured on all pre
and post-treatment cephalograms, in relation to
skeletally defined PMV line of Enlow et al.11 The
upper lip curvature was calculated as a difference
between upper lip thickness at labrale superioris and
upper lip thickness at point A in relation to PMV line.
Similarly the lower lip curvature was calculated as a
difference between lower lip thickness at labrale
inferioris and lower lip thickness at point B in
relation to PMV line. Various cephalometric
landmarks and the linear measurements used for the
measurement of depth of upper and lower lip
curvatures are shown in Fig.-3.
The ANN model was prepared by utilizing MATLAB
software. The model was trained with data of same
40 subjects. The model had two inputs, two outputs, a
total of 10 layers with 8 hidden layers, one input
layer and one output layer. The input and output layer
indices for upper and lower lip curvatures for non-
extraction and extraction groups are shown in table-1
and 2. The statistical regression analysis and ANN
analysis were done to find out any possible prediction
equation where pre-treatment variables can be used to
find post-treatment results.
STATISTICS
All the data were analyzed with MINITAB version
13.1 and SPSS version 11 softwares. The data were
subjected to the descriptive statistics for the
evaluation of mean, standard deviation and range etc.
One-way ANOVA was used for multiple group
comparison and Man-Whitney test was used for
group wise comparison. Stepwise regression analysis
was used to identify not only those pre-treatment
variables with the most likely influence on lip
changes but also to attempt to describe the extent of
variability in lip response that might be explained by
those variables. The P-value of 0.05 was considered
as level of statistical significance.
RESULTS
The change in the curvature of the upper and lower
lips following various combinations of premolars
extraction and non-extraction treatment is described
Artificial neural network (ANN) modeling and analysis for the prediction of change in the lip curvature following extraction and non-extraction orthodontic treatment __________________Nanda SB et al.
J Dent Specialities.2015;3(2):130-139 132
in table-3. The curvature of the upper lip was
changed significantly (P<0.05) following premolars
extraction and non-extraction orthodontic treatment
as compared to the lower lip. Correlation and
regression analysis for the measurement of
relationship between various pre-treatment
parameters to predict the post-treatment changes in
lip-curve is described in table-4. When analyzing the
results of stepwise regression, it became obvious that
only prediction of lower lip curvature change in
upper first and lower second premolars extraction
group was good enough with 95.3% explained
variance (Table-4).
The ANN predicted values for upper and lower lip
curvature change were very close to the actual
prediction values obtained from conventional
regression analysis. The neural network prediction
values for upper and lower lips curvature changes are
shown in Fig.-4. The results of random data of 10
patients which were considered for testing showed
very promising (Fig.-5). The mean error in the
prediction of upper and lower lip curvature change
was 29.6% and 7% respectively which were very less
as compared to the statistical regression analysis
(Fig.-6 and 7).
Table 1: The input and output layer indices for upper and lower lip curvatures for non-extraction group.
SN Input layers for
upper lip curvature
Input layers for
lower lip curvature
Output layers for
upper lip curvature
Output layers for
lower lip curvature
1 4.6 7.1 0.8 2.4
2 2.8 4.4 -2.8 -3.3
3 3 5.6 2 -0.2
4 3.3 8.5 0.5 -0.7
5 3.9 5.2 -5.1 -0.7
6 3.5 6.3 2.7 -0.3
7 4 11.7 -1.2 4.3
8 4.5 1 0.2 -5
9 2.5 4.5 -0.2 -1.2
10 5.2 2.6 1.4 -6.4
11 2.7 6.4 0.7 -5.5
12 4.5 5.2 1.7 2.5
13 1.8 6.5 -0.5 0.6
14 1.9 6.5 1 -1.7
15 4 3.9 -0.6 -2.1
16 4.6 8.3 0.9 3.8
17 4.9 8.3 1.1 -1.8
18 3.9 4.4 0.3 -0.3
19 5.1 6.9 1.7 1.3
20 4.2 9.7 1.7 2.6
Table 2: The input and output layer indices for upper and lower lip curvatures for extraction group.
SN Input layers for
upper lip curvature
Input layers for
lower lip curvature
Output layers for
upper lip curvature
Output layers for
lower lip curvature
1 6.2 5.4 0.2 0.9
2 5.1 6.9 1.7 1.3
3 7.3 10.3 -0.1 2.5
4 3.7 8.1 1.9 2.7
5 4.6 8.3 0.9 3.8
6 5.1 9.1 1.3 2.8
7 4.9 8.3 1.1 -1.8
8 3.4 7.6 1.1 -4.6
9 6.9 2.2 5.7 -2.8
10 6.7 2.3 1.6 -2.3
11 6.5 6.8 4.6 2.7
12 4 3.9 -0.6 -2.1
13 6.5 7.5 2 4.7
14 4 7.8 2.1 5.3
15 4.8 6 1.4 3.2
16 5 6.4 1.1 -0.6
17 5 6.8 0.6 0.5
18 6.2 5.4 0.2 0.9
19 3.3 8.5 0.5 -0.7
20 1.8 6.5 -0.5 0.6
Artificial neural network (ANN) modeling and analysis for the prediction of change in the lip curvature following extraction and non-extraction orthodontic treatment __________________Nanda SB et al.
J Dent Specialities.2015;3(2):130-139 133
Table 3: Changes in the upper and lower lip curvatures following extraction and non-extraction treatment
GROUP
UPPER LIP CURVE
PRE POST LIP CURVE CHANGE
MEAN+/-SD MIN MAX
4/4 Extraction 4.85+/-1.26 3.71+/-1.79 1.14+/-0.66 -0.1 1.7
4/5 Extraction 5.56+/-1.41 3.62+/-1.56 1.94+/-1.84 -0.1 5.7
5/5 Extraction 4.25+/-1.69 3.86+/-1.43 0.39+/-0.58 -0.5 1.4
Non Extraction 3.74+/-1.01 3.41+/-1.84 0.33+/-1.77 -5.1 2.7
ANOVA F
3.14
P 0.04*
GROUP
LOWER LIP CURVE
PRE POST LIP CURVE CHANGE
MEAN+/-SD MIN MAX
4/4 Extraction 8.37+/-1.09 7.44+/-2.81 0.93+/-3.03 -4.6 3.8
4/5 Extraction 5.65+/-2.43 3.99+/-1.43 1.66+/-3.66 -2.8 5.3
5/5 Extraction 6.73+/-1.1 6.59+/-1.69 0.14+/-0.71 -0.7 3.2
Non Extraction 6.15+/-2.46 6.74+/-2.16 -0.59+/-2.97 -6.4 4.3
ANOVA F
0.83
P 0.49NS
F – Variance ratio, * = P< 0.05 NS= Non-significant
Table 4: Stepwise regression predictions of upper and lower lip curvatures following extraction and non-
extraction treatment
GROUPS POST TREATMENT
LIP CURVE CHANGES
PREDICTION
EQUATION SE R² %
4/4 Extraction ULCC ULCC = 3.13 - 0.42 (ULC) 0.5 60.40%
LLCC LLCC = -3.24 + 0.52 (LLC) 2.9 7.30%
4/5 Extraction ULCC ULCC = -3.61 + 1.07 (ULC) 1.9 42.70%
LLCC LLCC = -6.24 + 1.41 (LLC) 0.9 95.30%
5/5 Extraction ULCC ULCC = -0.48 + 0.24 (ULC) 0.06 30%
LLCC LLCC = 5.65 - 0.76 (LLC) 1.3 32%
Non-
Extraction
ULCC ULCC = -1.01 + 0.35 (ULC) 1.79 4.10%
LLCC LLCC = -5.77 + 0.84 (LLC) 2.2 49%
ULCC=Upper lip curvature change, LLCC= Lower lip curvature change,
SE = Predicted Variation, R2 = Explained Variance
Fig. 1: The structure of an artificial neural network
Artificial neural network (ANN) modeling and analysis for the prediction of change in the lip curvature following extraction and non-extraction orthodontic treatment __________________Nanda SB et al.
J Dent Specialities.2015;3(2):130-139 134
Fig. 2: The basic components of an artificial neuron
Fig. 3: Various cephalometric landmarks, reference planes and linear parameters used for the evaluation of upper
and lower lip curvature changes. Cephalometric landmarks: Sphenoethmoidal point (Se), the intersection of the
Artificial neural network (ANN) modeling and analysis for the prediction of change in the lip curvature following extraction and non-extraction orthodontic treatment __________________Nanda SB et al.
J Dent Specialities.2015;3(2):130-139 135
greater wings of the sphenoid with the floor of the anterior cranial fossa; Pterygomaxillary point (Ptm), the inferior
and most posterior point on the anterior outline of the pterygomaxillary fissure; Point A (A); Projected point A (A’),
point constructed where a line, perpendicular to PMV plane and passing through skeletal A point intersects the soft
tissue outline; Labrale superius (Ls); Projected labrale superius (Ls’), point constructed where a line perpendicular
to the PMV plane and passing through labrale superius intersects the hard tissue outline; Labrale inferius (Li);
Projected labrale inferius (Li’), point constructed where a line perpendicular to the MPV plane passing through
labrale inferius intersects the hard tissue outline; Supramentale point (B); Projected supramentale point (B’), the
point of intersection of the soft tissue profile with a line drawn perpendicular to PMV plane through supramentale
(B point). Reference plane: Pterygomaxillary vertical (PMV) plane, plane drawn from the sphenoethmoid point (Se)
to the pterygomaxillary (Ptm) point. Linear parameters: 1. Upper lip thickness at Point A (A-A’); 2. Upper lip
thickness at labrale superius (Ls-Ls’); 3. Lower lip thickness at labrale inferius (Li-Li’); 4. Lower lip thickness at B
point (B-B’).
Fig. 4: The neural network prediction values for the upper and lower lips curvature changes.
Artificial neural network (ANN) modeling and analysis for the prediction of change in the lip curvature following extraction and non-extraction orthodontic treatment __________________Nanda SB et al.
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Fig. 5: Prediction of upper and lower lip curve change for the testing data.
Artificial neural network (ANN) modeling and analysis for the prediction of change in the lip curvature following extraction and non-extraction orthodontic treatment __________________Nanda SB et al.
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Fig. 6: The comparison of percentage of mean error in the prediction of upper lip curve change for testing
data by ANN analysis and regression analysis.
Fig. 7: The comparison of percentage of mean error in the prediction of lower lip curve change for testing
data by ANN analysis and regression analysis.
Artificial neural network (ANN) modeling and analysis for the prediction of change in the lip curvature following extraction and non-extraction orthodontic treatment __________________Nanda SB et al.
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DISCUSSION
Artificial neural network (ANN) models have been
used widely in medicine for solving a wide variety of
problems.12-17 However in dentistry, ANN models
have been tried occasionally.6,8,18-20 In orthodontics,
ANN models have been used for the analysis and
classification of human craniofacial growth,6
prediction of electromyographic signal values of
anterior temporal muscle among children undergoing
orthodontic treatment7 and deciding the need of
extractions prior to orthodontic treatment.8
From the present study we found that the mean
change in the depth of upper lip curvature following
premolars extraction treatment was significantly
different as compared to the non-extraction treatment.
However, there was no change in lower lip curvature
following premolars extraction and non-extraction
treatment. However in contrast to our observation
many previous studies reported no change in the
depth of upper and lower lip curvature amongst the
various extraction and non-extraction treatment.21,22
The inherent morphology of the soft tissue appeared
to be the greatest determinant of lip curve behavior
with extraction and non-extraction treatment.22
Wholley and Woods also reported that changes in the
depths of curvature of both the upper and lower lips
were not solely dependent on the selection of a
particular premolar extraction sequence.23 Instead,
there were wide ranges of individual variation in the
changes in the depths of the lip curves.23 From the
present study it was appear that the change in
midface soft tissue was more dependent on changes
in the underlying hard tissue as compared to the
lower face soft tissue. But previous study done by
Moseling and Woods reported that the midface soft
tissue was less dependent on changes in the
underlying hard tissues than do the lower face soft
tissue.21
An important observation that we found from the
stepwise regression predictions (table-2) was that
only prediction of lower lip curve change following
upper first and lower second premolars extraction
was good enough with 95.3% explained variance.
Although the ANN predicted values for upper and
lower lip curvature changes were very close to the
actual prediction values obtained from statistical
regression analysis, but the mean error was only
29.6% for upper lip and 7% for lower lip as
compared to the conventional regression analysis.
The major drawback of this present study is that the
ANN model was trained with data of only 40
subjects. Thus an ANN model from data of very large
samples needs to be prepared to establish an accurate
decision making system.
Thus the artificial neural network analysis can be the
solution to those problems which cannot be easily
solved with traditional methods. Neural network
expert systems may be trained with only clinical data
and as such can be used where 'rule based' decision
making may not always be possible. So the artificial
neural network analysis is a promising tool to
produce clinical decision support systems (CDSS) to
provide expert support for health professionals. As
information technology applications for dental
practice developing rapidly and will hopefully
contribute to produce clinical decision support
systems (CDSS) of orthodontics and in turn impact
patient care.
CONCLUSIONS
The following conclusions were drawn from the
present study
1. Extraction and non-extraction treatment had
significant effect on the curvature of upper lip
change.
2. The ANN model analysis was more accurate
for the prediction of lip curvature change
following extraction and non-extraction
orthodontic treatment as compared to the
conventional statistical regression analysis.
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How to cite this article: Nanda SB, Kalha AS, Jena AK, Bhatia V,
Mishra S. Artificial neural network (ANN) modeling and analysis for the prediction of change in the lip curvature following
extraction and non-extraction orthodontic treatment. J Dent
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Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
____________________________________________________________________Original Research
J Dent Specialities.2015;3(2): 140-145 140
Detection of apoptosis in human periodontal ligament during
orthodontic tooth movement
Ritu Duggal1, Neeta Singh2
ABSTRACT Aim: To compare distribution of apoptotic cells in the Periodontium following Orthodontic
force application, to study the apoptotic index and co-relate with different phases of tooth
movement.
Material and methods: 100 patients, age 12-20 years, of class II div 1 malocclusion, were
randomly divided into Groups I to V, requiring first premolars extraction with fixed
Mechanotherapy. After leveling, canine was retracted using closed coil spring (100 gm
forces). Surgical extraction of premolar was performed on 0, 3,7,14 & 21 days.
Periodontium tissue was processed and apoptosis was evaluated by TUNEL assay.
Apoptotic cells were counted from 4 different fields per slide and compared with the basal
group.
Results: The mean Apoptotic Index increased from day 3 and peaked at day 7 for both
compression and tension sides. On tension side, at days 14 & 21 apoptosis wasn’t
significant indicating earlier recovery. On compression side, there is more gradual decrease
in apoptosis with lowest mean values at day 21, though not same as the basal level,
indicating that the periodontal tissues require more than 21 days for complete recovery. The
overall difference in apoptotic rate was statistically significant for both compression and
tension sides.
Conclusion: Tissue response is a time-dependant normal physiological process where
periodontal cells are cleared by apoptosis. The correlation coefficient value indicates the
apoptotic activity increased with force on compression side & increased significantly on
tension side too, signaling towards force-dependant direct relation between the two. Cells
on tension side showed a more rapid rate of recovery as compared to compression side.
Keywords: Periodontium, Orthodontic, Mechanotherapy, Force-dependant
INTRODUCTION
he Mechanical force during tooth movement was
reported to create compressed and cell-free areas,
so called hyalinized tissue, in the periodontal
membrane (Reitan and Rygh 1994). Hyalinized
tissues were described as necrotic (Rygh 1972, 1973)
or degenerating (Nakamura, Tanaka and Kuwahara,
1996) tissue from ultra-structural observations. The
precise mechanism by which periodontal ligament
cells disappear at the compressed area during tooth
movement remains unclear. In the present study we
examined whether periodontal ligament cells undergo
apoptosis at the compressed area during tooth
movement by using terminal deoxynucleotidyl
transferase-mediated dUTP nick end labeling
(TUNEL).
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DOI: 10.5958/2393-9834.2015.00003.0
OBJECTIVES
1. To study the Apoptotic Index in the periodontal
tissue clearance during tooth movement.
2. To compare tissue changes in the Periodontium
on the 3rd, 7th, 14th & 21st day after application of
orthodontic force.
3. To correlate the above findings with different
phases of orthodontic tooth movement.
MATERIAL AND METHODS
The study comprised of 100patients, age 12-20 years,
having Class II division 1 malocclusion requiring
first premolars extraction to be treated with Fixed
Mechanotherapy using Standard edgewise
Prescription (0.022”×0.028” slot). Leveling and
alignment was done using .016”, 018” and .020”
stainless steel wires. Sentalloy closed coil springs
were attached between canine & first premolars (200
grams force). Ethical clearance was obtained from
the Ethics Committee of All India Institute of
Medical Sciences, New Delhi with reference number
(A-11-6/4/05) dated 8 August 2005. Written consent
was obtained from each patient prior to their
inclusion in the study. The patients were divided into
five groups on the basis of the staging of the
premolar extraction with respect to time. (Table 1)
1Professor, Department of
Orthodontics and Dentofacial Deformities, Centre for Dental
Education and Research, A.I.I.M.S.,
New Delhi. 2Professor, Department of
Biochemistry, All India Institute of
Medical Sciences, New Delhi
Address for Correspondence: Dr. Ritu Duggal
Professor
Department of Orthodontics and Dentofacial Deformities
Centre for Dental Education and
Research A.I.I.M.S., New Delhi.
Email: [email protected]
Received: 10/01/2015
Accepted: 15/04/2015
T
Detection of apoptosis in human periodontal ligament during orthodontic tooth movement ______Duggal R et al.
J Dent Specialities.2015;3(2):140-145 141
1. Group I–no force was applied
2. Group II–force applied for 3 days
3. Group III–force applied for 7 days
4. Group IV–force applied for 14 day
5. Group V–force applied for 21 days
In Group I, the 1st premolar teeth were extracted prior
to any force application. In the other groups, force
was applied prior to 1st premolars extraction.
Procedure for Extraction of Premolar:
A Crevicular incision was made around the premolar
tooth. Two vertical incisions were given on the
buccal surface on the mesial and distal aspects of the
tooth, followed by placement of two vertical
osteotomy incisions with Tungsten Carbide Surgical
burs, on the buccal surface in the mesial and distal
aspect of premolar. Horizontal osteotomy cut
joining the mesial & distal vertical cuts was given.
During osteotomy, lingual cortical plate was
preserved.
Tissue Sample Collection:
The extracted teeth, along with their Periodontium,
were collected and were frozen at -70ºC and
subsequently, fixed with Zambanis fixative solution.
The fixed tissues were dehydrated with graded
alcohol & embedded in paraffin. Sections of
Periodontium, 6μ thick, were then cut & mounted on
Polylysin-coated glass slides.
Henceforth, TUNEL assay was carried out to detect
apoptosis. The Dead EndTM Colorimetric TUNEL
System is a non-radioactive system designed to
provide simple, accurate and rapid detection of
apoptotic cells in situ at single-cell level. The slides
were observed under 20 X magnifications. TUNEL-
positive cells were counted from 4 different fields on
each slide, with 500 cells per field.
The Apoptotic Index, was determined using the
formula
AI =
Total no. of cells showing apoptotic nuclei X 100
500 X 4
STATISTICAL ANALYSIS
SPSS 12 software was used for all statistical analysis.
The control group (group I) & the experimental
groups (group II to V) were compared for the mean
number of TUNEL- positive cells by applying one
way ANOVA and Kruskal Wallis test. Statistically
significant value was placed at p<0.05. Further the
compression site was compared to the tension site in
the experimental group by ANOVA test and p<0.05
was considered statistically significant.
RESULTS
Day 0, (Group I)
On compression side, the Mean Apoptotic Index was
found to be 2.22±0.76 with a range of 1.87-2.5 ( p
value .001). On tension side, the Mean Apoptotic
Index was found to be 1.22±0.46 with a range of 1.0-
1.4(p value .014). The Mean Apoptotic Indices on
compression & tension sides at day 0 had a direct
correlation seen at .47 which was found to be
statistically significant (p value .03).
Day 3, Group II
On compression side, the Mean Apoptotic Index was
found to be 4.91±2.5with a range of 3.7-6.08 ( p
value .001). On tension side, the Mean Apoptotic
Index was found to be 2.66±1.43 with a range of 1.9-
3.3(p value .001). The Mean Apoptotic Indices on
compression & tension sides at day 0 had a direct
correlation seen at .63 which was found to be
statistically significant (p value .003).
Day 7, Group III
On compression side, the Mean Apoptotic Index was
found to be 12.75±2.9 with a range of 11.3-14.1 (p
value .001). On tension side, the Mean Apoptotic
Index was found to be 6.56±3.13 with a range of 5.1-
8.03 (p value 14). The Mean Apoptotic Indices on
compression & tension sides at day 0 had a direct
correlation seen at .19 which was found to be
statistically non- significant. (p value .41).
Day 14, Group IV
On compression side, the Mean Apoptotic Index ±
S.D. was found to be 8.28±2.9 with a range of 6.9-9.6
(p value .001). On tension side, the Mean Apoptotic
Index ± S.D. was found to be 3.53±1.77 with a range
of 2.7-4.3 (p value .12). The Mean Apoptotic Indices
on compression & tension sides at day 0 had a direct
correlation seen at .67 which was found to be
statistically significant (p value .001).
Day 21, Group V
On compression side, the Mean Apoptotic Index was
found to be 5.47±1.23 with a range of 4.8-6.05 (at
95% confidence interval, p value .43). On tension
side, the Mean Apoptotic Index ± S.D. was found to
be 3.14±1.03 with a range of 2.6-3.6(p value .4). The
Mean Apoptotic Indices on compression & tension
sides at day 0 had a direct correlation seen at .46
which was found to be statistically significant (p
value .04).
The Mean Apoptotic Index on compression side in
control group at day 0 as 2.22±0.76. At day 3, the cell
index had increased to 4.91±2.5 which was found to
be statistically significant (p value .001). The Mean
Apoptotic Count continued to increase and the
Detection of apoptosis in human periodontal ligament during orthodontic tooth movement ______Duggal R et al.
J Dent Specialities.2015;3(2):140-145 142
highest values were observed on day 7 (12.75±2.9). It
decreased thereafter, as observed on day 14
(8.28±2.9) and day 21 (5.47±1.23).
The counts at day 7 & day 14 were statistically
significant (p value .001) while the value observed at
day 21 did not show a statistically significant
difference when compared to day 0, although the
count had not reached the observed count at day 0.
The Mean Apoptotic Index on tension side in control
group at day 0 was 1.22±0.46. At day 3, the cell
index had increased to 2.66±1.43 which was found to
be statistically significant (p value .05). The count
continued to increase and the highest values were
observed on day 7 (6.56±3.13) and decreased
thereafter. The counts observed at day 14 (3.53±1.77)
and day 21 (3.14±1.03) did not show any significant
difference in their values and the mean indices were
almost twice that at day 0 (1.22±0.46).
The cell count at day 7 was statistically significant (p
value .001) but at day 14 & 21, no statistically
significant difference (p value .05) was observed
when compared to day 0.
The overall apoptotic activity was found to be
statistically significant for both compression and
tension sides (p value .05), irrespective of time.
A direct correlation of apoptotic activity between
compression side & tension side was seen at day 3
(.63), day 14 (.67) & day 21 (.46), which was
statistically significant (p value .05).
At day7, the correlation had lower positive value
(0.19) that wasn’t statistically significant (p value
.05).
The overall correlation coefficient (0.73) of apoptotic
activity on compression side with tension side was
statistically significant (p value .001), signaling a
direct relation between the two.
With respect to age and sex, no statistically
significant difference in correlation of apoptosis on
compression and tension sides was seen. (Table 2)
The apoptosis of periodontal cells on compression
side with respect to time was statistically
significantly (p value .05) and on tension side was
insignificant.( Fig 1)
Table 1: Distribution of sample into 5 groups
Group Sample Mean age Duration after which
force applied
Group I 10 M & 10 F 13.5 years no force
Group II 10 M & 10 F 16 years 3 days
Group III 10 M & 10 F 14.29 years 7 days
Group IV 9 M & 11 F 14.2 years 14 days
Group V 11 M & 9 F 14.23 years 21 days
M: male, F: female
Table 2: Trend of average values of apoptotic index during the study on tension & compression sides
0 days 3 days 7 days 14 days 21 days
Comp 2.2265 4.91 12.755 8.283 5.4715
Tens 1.2255 2.6605 6.569 3.5385 3.145
Fig. 1: Trend of average values of apoptotic index during the study on tension & compression sides
0
5
10
15
20
25
0 days 3 days 7 days 14 days 21 days
Tens
Comp
Detection of apoptosis in human periodontal ligament during orthodontic tooth movement ______Duggal R et al.
J Dent Specialities.2015;3(2):140-145 143
DISCUSSION
All connective tissues within the body are in a
constant state of flux, synthesizing, degrading and
reorganizing both the macro and micro molecular
components of the matrix to maintain their structural
and functional integrity. The state is considered to be
of dynamic equilibrium wherein the catabolic and the
anabolic processes act in synergy. This is of
particular importance in the periodontal connective
tissues, since the periodontal ligament is known to
have a high cellular turnover rate and is under
constant occlusal and non-occlusal loading forces.
The basis of orthodontic movement lies in the very
fact that this dynamic equilibrium can be disturbed
by the application of orthodontic forces which alter
the local environment thus leading to selective areas
of heightened cellular activity within the periodontal
ligament which further leads to selective remodeling
of the supporting alveolar bone. Under normal
physiologic conditions, a tooth is considered to be at
‘rest’ in its socket. Application of light orthodontic
force is known to cause direct resorption of the
adjacent bone interface as periodontal ligament
vitality is preserved, thus allowing the osteoclasts to
cause bone resorption from the adjacent vital
periodontal ligament-bone interface. Thus, such
forces are considered to be more physiologic and
efficient in causing tooth movement. Thus, the
control of orthodontic forces becomes extremely
important and desirable to perform physiologic tooth
movement.
One of the important indicators of direct resorption is
the presence of apoptotic cells in the adjacent
periodontal ligament bone interface. Studies have
shown that apoptosis is marker of bone /connective
tissue remodeling. Apoptosis plays a crucial role in
developing and maintaining health by eliminating
old, unnecessary and unhealthy cells without
releasing harmful substances into the surrounding
area.1 The cell demise via apoptosis is a genetically
controlled energy dependent, and takes place via a
coordinated, predictable and predetermined pathway.
Jilka et al demonstrated that the missing osteoblasts
die by apoptosis and those growth factors and
cytokines produced in the bone microenvironment
influence this process.2,3,4 Drugs have also been
known to effect apoptosis.5,6
In our study, we have tried to evaluate the efficacy of
light orthodontic forces in causing direct remodeling
of the adjacent bone surface studied by analyzing the
number of apoptotic cells in the periodontal ligament
of the teeth subjected to light forces at different time
intervals, since apoptosis is an indicator of
physiologic cell death and thus, would be more
closely related to direct bone resorption. It has been
already proved by W Zhong that cyclic stretching
force induces early apoptosis of periodontal ligament
cells.7
The main aim of our study was to determine whether
apoptosis of periodontal cells occurs during
orthodontic tooth movement and when apoptotic
activity reaches a maximum level. It was found that
significant apoptosis of cells does occur on both
compression and tension sides, irrespective of time
interval. Noxon et al reported that osteoclasts are at
least cleared in part by apoptosis during experimental
tooth movement in rats.8
As orthodontic force is applied, a signaling cascade
ensues causing release of the biochemical molecules
in periodontal ligament. These molecules in turn
cause a transient inflammatory response and cell
death leading to an increase in observed apoptosis.
As we applied force over a period of 21 days, cell
apoptosis started increasing from day 0 to day 3. It
signifies that apoptotic changes start appearing in the
early phase of orthodontic tooth movement and this
time period varies from 0 to 3 days. Studies by
Hamaya et al reveal that osteocytes showed apoptotic
morphology at 6 hours, 12 hours and 1 day.9 At 2 and
4 days, several osteocytes exhibited characteristics of
necrosis and destructive images of the surrounding
bone matrix. In similar studies by Hatai et al,
TUNEL-positive staining of periodontal ligament
cells began to appear at the compressed areas
12 hours after tooth movement in mice, being
maximum at 24 hours and disappearing at 48 hours,
with direct and undermining bone resorption
beginning at the same area 72 hours after tooth
movement.10 PGE samples in alveolar bone peaked at
2 & 7 days (Joseph 1986), IL-1β and IL-6 was
observed to reach a maximum on day 3 and to
decline thereafter (Alhashimi et al, 2001).11,12
The biochemical signal molecules can also be
detected in GCF during experimental tooth
movement, provided plaque and other systemic
conditions do not interfere with the cellular
responses. The time period when the levels of these
biomolecules are raised can be correlated with the
onset of apoptosis (0 to 3 days in our study) and its
peak activity (day 7 in our study). Of significance
acid phosphatase is recognized as an important
marker of osteoclast activity and bone resorption,
whereas bone-specific alkaline phosphatase has been
reported as a biomarker indicative of bone formation.
Christenson 13 reported that alkaline phosphatase was
observed to peak during the first 3 weeks of
treatment, while acid phosphatase was seen to
increase over the subsequent 3–6 weeks following
initiation of treatment (Insoft et al).13,14 IL-8
concentration in the GCF show gradual increase up to
10 days and declined on day 30 at the compression &
tension sites (Tuncer et al).15 Induction of IFN-
gamma at both m-RNA and protein levels was
significantly higher on day 3. The signal gradually
became stronger on day 7 and remained high on day
10 (Alhashimi et al).16 CD40 is a cell surface receptor
Detection of apoptosis in human periodontal ligament during orthodontic tooth movement ______Duggal R et al.
J Dent Specialities.2015;3(2):140-145 144
(expressed on monocytes, dendrite cells, and IL-6 or
IL-8 secretion by ligation of endothelial cells,
basophiles, epithelial cells, and fibroblasts) which
belongs to the tumor necrosis receptor family (TNF-
R). The strongest expression of CD40+ was observed
on day 3, decreased on day 7, and reached a low level
on day 10 after application of orthodontic force. In
contrast, in the treated animals CD40 ligand was
expressed on day 3, the expression was enhanced on
day 7, and was more pronounced on day 10. CD40L-
expressing cells were found predominantly around
hyalinized tissue in the resorption zone and the
tension areas (Alhashimi et al).17 Xiaozhe et al
assessed the biological relevance between SFRP1
expression and the onset of apoptosis.18 The number
of TUNEL-positive fibroblasts gradually increased in
the periodontal ligament 12 hours after the
application of mechanical stress, sharply raised at 24
hours and peaked at 2 days. Simultaneously, an
increased SFRP1 expression was seen in mice
periodontal ligament during force-induced apoptosis.
As quoted in the above discussion, it can be seen that
the initial phase varies between 0 to 3 days and peak
between 4 to 7 days, these findings support our
results of beginning of apoptosis and maximum
apoptosis observed in our study.
Our study reveals that significant amount of
apoptosis occurs at days 3, 7 and 14 on compression
side and at days 3& 7 on tension side. Even Noxon et
al, (2005) had reported that significant difference
existed in the overall percentage of TRAP/ApopTag-
positive nuclei between the control and the treatment
groups at 3, 5, and 7 days.4
Maximum activity was seen at day 7 for both
compression and tension sides. Rana et al suggested
that maximum apoptosis occurs approximately 3 days
after the insertion of appliance in the periapical tissue
but the study was conducted in rats.19 Though the
peak apoptotic activity was usually observed around
2-3 days (as quoted in the above studies), but most of
them were conducted in rats. The rate of metabolism
varies in rats and humans the morphological changes,
which take 2 days in humans to appear, are seen as
early as 2hrs in rats. This might explain the variation
in the time period of peak apoptosis observed.20,21
In our study, though significant apoptotic activity
was seen at day 14 on compression side but it had
started decreasing when compared to day 7 and as it
approached day 21, no significant apoptosis occurred.
Whereas on tension side, apoptotic activity had
reduced at day 14 & 21, but it wasn’t significant.
This highlights upon the fact that removal of dead
cells and their replacement on tension side begins
after 7 days of force application but on compression
side it starts after 14 days of force application These
findings are supported in the study conducted by
Mabuchi et al who investigated the cellular responses
of periodontal ligaments during tooth movement and
found that the ratios of PCNA-positive cells on the
tension side 3 and 7 days after rubber block insertion
were higher than those on the pressure side.22 The
ratios of PCNA-positive cells on the tension side
were highest at day 3 after insertion and then
decreased during the remainder of the experimental
period. On the pressure side, the ratios of PCNA-
positive cells increased up to day 10 post insertion,
and then decreased from 14 to 28 days. The ratios of
TUNEL-positive cells on both the tension and the
pressure sides increased throughout the entire
experimental period.
The level of activity on both compression and tension
sides hadn’t reached the basal level at day 21. Even
Yijin et al revealed that maximum number of
osteoclasts in PDL are seen from 2 weeks to 4 weeks
during experimental tooth movement in rats with a
positive correlation between the rate of tooth
movement and osteoclast numbers, especially in
young rats.23 This clearly indicates that the cells take
more time (i.e. 21 days) to recover to their state of
physiologic equilibrium. Moreover, it is a well
established fact that upon appliance activation, the
stressed periodontal tissues need a period of at least
3-4 weeks for recovery. This again supports our
findings why the mean apoptotic index could not
reach the basal level at day 21.
A direct correlation between compression & tension
was observed as increase in apoptotic activity with
force on compression side led to its increase on
tension side too, signaling towards a force-dependant
direct relation between the two.
No correlation of apoptotic activity was seen with
respect to age & sex which is in accordance to
previous studies.
Present study is based on assumption that the
morphology of alveolar bone is same in both the
maxilla and mandible and hence, their physiological
apoptotic activity will be same, regardless of whether
maxillary or mandibular premolar is extracted.
CONCLUSION
Orthodontic tooth movement is a physiologic
process rather than pathologic that causes
remodeling of tissues via apoptosis.
As force is applied, significant apoptosis does
occur with time on both compression and tension
sides, with peak activity seen at 7 days.
As apoptotic activity increased with force on
compression side, the apoptotic activity
increased significantly on tension side too,
signaling towards a force-dependant direct
relation between the two.
The level of apoptosis on tension side starts
reducing earlier indicating a more rapid recovery
of cells as compared to compression side.
Detection of apoptosis in human periodontal ligament during orthodontic tooth movement ______Duggal R et al.
J Dent Specialities.2015;3(2):140-145 145
Hence, from our study we can conclude that tissue
response to orthodontic tooth movement is a time-
dependant normal physiological process; the
periodontal cells are cleared by apoptosis.
Acknowledgement The authors are grateful to Indian Council of Medical
Research for providing grant for the study.
Financial competing interests:
This project received a grant from Indian Council of
Medical Research, New Delhi, India. This
organization is not financing this manuscript or the
article-processing charge.
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How to cite this article: Duggal R, Singh N. Detection of
apoptosis in human periodontal ligament during orthodontic tooth movement. J Dent Specialities. 2015;3(2):140-145.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
____________________________________________________________________________Original Research
J Dent Specialities.2015;3(2):146-149 146
Assessment of 4% ocimum sanctum and 0.2% chlorhexidine irrigation
as an adjunct to scaling & root planing in management of chronic
periodontitis - a randomized controlled trial
Jayshree Gaur1, Joohi Chandra2, Shubhi Chaudhry3, Shubhra Vaish4, Vidya Dodwad5
ABSTRACT Background: Ocimum sanctum is a plant which is of great medicinal value and has
various properties for curing and preventing disease. Hence a study was conducted to
determine the effectiveness of Ocimum sanctum on bacterial plaque and its comparison
with Chlorhexidine gluconate which is considered as the gold standard.
Materials and Methods: 30 chronic periodontitis patients were randomized into two
groups. Group A received scaling and root planing plus intra-pocket irrigation of Ocimum
sanctum (n= 15) and Group B received scaling and root planing plus intra-pocket
irrigation with Chlorhexidine gluconate (n = 15). Clinical parameters including the plaque
index, gingival index, pocket probing depth and clinical attachment level were assessed at
baseline and 30 days. Statistical analysis was carried out using SPSS version 17.
Statistical significance of P ≤ 0.001 was considered.
Results: Our data showed that Ocimum sanctum was equally effective in reducing
periodontal indices as chlorhexidine. Significant reduction in all clinical parameters were
observed over a period of four weeks in both the test and the control groups.
Conclusion: The results of the present study revealed that subgingival irrigation with 4%
Ocimum sanctum may prove to be effective owing to its ability in reducing plaque
accumulation, gingival inflammation and bleeding and has no side effects as compared to
chlorhexidine.
Keywords: Chlorhexidine, Ocimum sanctum, Irrigation, Periodontitis
INTRODUCTION
eriodontitis is an inflammatory disease which
causes pathological alterations in tooth
supporting tissues and hence leads to loss of
periodontal tissues. Scaling and root planing (SRP) is
considered as the effective means of treating
periodontitis.1 However, the failure to gain access to
deep pockets or furcations often results in a
substantial variation in its effectiveness.2 To
compensate for these technical limitations, use of
antimicrobials has been established which prevents
early microbial recolonization and ultimately ensures
significant chances of clinical improvements.3 From
the past four decades subgingival irrigation has been
used as a useful adjunct to scaling and root planing
for the treatment of periodontal diseases.4
Subgingival delivery of antimicrobial agents have
been shown to be effective both, in office as well as
in home hygiene regimes.
Various compounds have been evaluated for their
effectiveness on plaque and gingivitis including
bisbiguanides such as chlorhexidine gluconate5
pyrimidines, quaternary ammonium compounds,
essential oils6 phenolic compounds, oxygenating
agents, halogens etc. Among these agents,
chlorhexidine is the most studied and effective
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antiseptic for inhibition of plaque and gingivitis,
when used as mouth rinse twice daily7.
Topical treatment with 0.2% Chlorhexidine gluconate
(CHX) has been found to be particularly efficacious
for the control of supragingival plaque8 but simple
mouthrinses do not allow access of the substance to
the subgingival area.9 It has been recently shown that
subgingival irrigation with CHX seems to cause
significant changes in both clinical and
microbiological parameters in humans10,11 and
animals12 although some observations contradict
these findings.13
Medicinal plants are widely used in curing and
controlling various diseases in day to day practice.
Despite the presence of extracts of herbs, or synthetic
chemicals based on herbs in modern day medicine
still the natural form offers less side effects and a
cheaper alternative to pharmaceutical drugs.14
Ocimum sanctum is one such natural substance, also
known as the “Queen of herbs”. In ancient literature,
it is considered as a sacred medicinal plant and is
frequently mentioned as one of the main pillars of
herbal medicine. Tulsi has been renowned as a
general tonic and vitalizer, “The Elixir of Life”.14 Oil
of O. sanctum contains five fatty acids (stearic,
palmitic, linoleic, oleic and linolenic acids) which is
considered to be a good source of beta carotene,
calcium, vitamin C. Also, it contains various volatile
substances (including estragol, eugenol, linalool,
methyl chavicol and small quantities of methyl
cinnamate, cineole, and other terpenes), tannins,
camphor, flavonoids, triterpene, urolic acid. Leaves
are diaphoretic and antiperiodic which are used in
patients suffering from bronchitis, gastric and hepatic
disorders. Decoction of leaves is often recommended
1,2,3Post Graduate Student, 4Professor 5Professor and Head, Department of
Periodontology and Oral Implantology, ITS-CDSR, Muradnagar, Ghaziabad,
Uttar Praedesh
Address for Correspondence:
Dr. Jayshree Gaur,
Post Graduate Student, Department of
Periodontology and Oral Implantology,
ITS-CDSR, Muradnagar, Ghaziabad, Uttar Praedesh
Email: [email protected]
Received: 05/03/2015
Accepted: 18/08/2015
P
Assessment of 4% ocimum sanctum and 0.2% chlorhexidine irrigation as an adjunct to scaling & root planing in management of chronic periodontitis - a randomized controlled trial ___________________________________________________________________Gaur J et al.
J Dent Specialities.2015;3(2):146-149 147
for cough, malaise and in cold. It is a good mosquito
repellant as well. Oil extracted from flowers can also
be used to cure skin diseases and ring worm
infections. 15
Ocimum sanctum seed oil modulates both humoral
and cell mediated immune responsiveness as well as
it inhibits acute as well as chronic inflammation. The
essential oil and seed extract act by the inhibition of
cyclo-oxygenase and lipoxygenase pathways.16 It may
be considered as a drug of natural origin which has
both the anti-inflammatory as well as the anti-ulcer
activity.17
As studies related to herbal mouth rinses are lacking
and research in this area is necessary to generate the
evidence. Hence, this study was planned with the
objective to evaluate clinically the efficacy of 4%
Ocimum sanctum irrigation in preventing plaque
accumulation and gingival inflammation in
comparison with commercially available 0.2%
chlorhexidine (CHX).
MATERIALS AND METHODS
30 chronic periodontitis patients were selected from
the OPD of Department of Periodontology and Oral
Implantology, I.T.S Dental College, Muradnagar,
Ghaziabad. The experimental procedures were
undertaken with the understanding and written
informed consent of the patient and the study was
approved by the ethical committee of the institution.
A randomized, controlled clinical trial was conducted
to compare the efficacy of scaling and root planing
plus pocket irrigation with Ocimum Sanctum versus
Chlorhexidine in patients diagnosed with chronic
periodontitis. Patients of both the sexes between ≥ 28
years of age, diagnosed with chronic periodontitis
and periodontal pocket measuring ≥ 5 mm, patients
who were nonsmokers or smoking < 5 cigarettes /day
were included in the study. Subjects on antibiotics for
last three months and who had undergone periodontal
therapy in the past six months, patients with systemic
diseases, smokers, alcoholics and patients with less
than 8 teeth in the oral cavity were excluded from the
study. 30 sites were randomly divided into two
groups. In Group A, 15 sites were treated with
scaling and root planing plus intra pocket irrigation
with Ocimum Sanctum and in Group B, 15 sites were
treated with scaling and root planing plus intrapocket
irrigation with 0.2% chlorhexidine was done. Each
site was irrigated with 2 ml of solution, thrice at 15
minutes of interval.
PREPARATION OF EXTRACT
The extract was prepared as described by Aggarwal
et al18. The preparation of Ocimum sanctum extract
was done in the Department of Pharmacy ITS Dental
College Muradnagar.
Leaves of Ocimum sanctum were taken from the
institutional nursery and were washed and dried
under controlled conditions. The dried leaves were
then powdered finely. 300 grams of finely powdered
leaves of Ocimum sanctum were then macerated with
100% ethanol for a week in a round bottom flask.
To avoid effect of light on the active ingredients, the
flask was kept in dark. Filteration of the extract was
done through a muslin cloth for coarse residue and
finally through Whatman No. 1 filter paper. To obtain
a solid residue of Ocimum sanctum extract, the so
obtained filter was reduced at a low temperature < 50
degree Celsius. 18g of residue (extract) was obtained
from 300 g of Ocimum sanctum powder dissolved in
1L of ethanol and thus the yield was 6% w/w. A final
concentration of 4% (w/v) was obtained after
suspending the extract in polyethylene glycol (20%
v/v) and sterile distilled water. Flavouring agent
0.005% spearmint oil was also added to the extract
(Fig. 1and 2).
Patients were evaluated after 30 days interval.
Periodontal assessments were performed using the
Plaque Index using (Turesky Gilmore Glickman
modification of Quigley Hein Plaque Index, 1970)19,
Gingival Index (Loe & Silness, 1963)20, Probing
Depth and Clinical Attachment Level were measured
using UNC 15 probe.
Fig. 1: Armamentarium for preparation of 4%
Ocimum sanctum extract
Fig. 2: 0.2% Chlorhexidine gluconate and 4%
Ocimum sanctum extract
Assessment of 4% ocimum sanctum and 0.2% chlorhexidine irrigation as an adjunct to scaling & root planing in management of chronic periodontitis - a randomized controlled trial ___________________________________________________________________Gaur J et al.
J Dent Specialities.2015;3(2):146-149 148
Graph 1: Change in clinical parameters at
baseline and 30 days between the two groups
Table 1: Change in clinical parameters at baseline
and 30 days between the two groups
0.2%
Chlorhexidine
4%
Ocimum
sanctum
P
value
GI Baseline
30 days
1.47 ±0.38 1.67± 0.237
0.875 ±1.13 1.1 ±0.21 < 0.01
PI Baseline
30 days
1.4 ±0.56 1.1 ±0.316
1.1 ±0.316 1.0 ±0.00 <0.331
PD Baseline
30 days
5.6 ±0.576 5.8 ±0.422
3.3 ±0.483 4.6 ±0.576 <0.001
CAL Baseline
30 days
6.3±0.822 6.8 ±0.422
3.5 ±0.527 5.7 ±0.625 <0.001
STATISTICAL ANALYSIS
SPSS 17 was used for the results assessment. T test
was used to analyze the plaque and gingival index,
probing depth and clinical attachment level in the two
groups. P ≤0.001 was considered as statistically
significant.
RESULTS
No statistical differences were observed for baseline
variables Table 1. The mean plaque and gingival
scores for the Group I, II are depicted in Table 1. T
test was used to analyze the reduction in plaque and
gingival index, probing depth and gain in clinical
attachment level in the two groups. There was a
significant decrease in the plaque and gingival index
in both the Ocimum sanctum and chlorhexidine
groups at 30 days (P < 0.001) (Graph 1). Significant
reduction was seen in all clinical parameters for both
the groups at 30 days, though chlorhexidine group
showed better results as compared to Ocimum
sanctum group but difference was not statistically
significant. The difference in the decrease in plaque
and gingivitis between Ocimum sanctum and
chlorhexidine groups was not statistically significant.
Data showed that there was no significant difference
between Ocimum sanctum and chlorhexidine for any
clinical parameters throughout the study.
DISCUSSION
Our data showed that Ocimum sanctum was equally
effective in reducing periodontal indices as
chlorhexidine. The results demonstrated a significant
reduction in all clinical parameters in both groups
over a period of four weeks (Table 1). During the
study, Ocimum sanctum reduced plaque formation
which may be attributed to the fact that the
antibacterial agents present in Ocimum sanctum i.e.
Eugenol (l-hydroxy-2-methoxy-4-allylbenzene),
Carvacrol (5-isopropyl-2-methylphenol), Linalool
(3,7-dimethylocta-1,6-dien-3-ol), Caryophyllene
(4,11,11-trimethyl-8-methylene-bicyclo-4-ene),
Ursolic acid (2,3,4,5,6,6a,7,8,8a, 10,11,12,13 14-
btetradecahydro-1H-picene-4a-carboxylic acid) and
Methyl carvicol (also called Estragol: 1- allyl-4-
methoxybenzene). Also, the stem and leaves of
Ocimum sanctum contain a variety of constituents
that forms high molecular weight complexes with
soluble proteins in saliva, causes bacterial lysis on the
tooth surface and saliva and interferes with bacterial
adherence mechanisms on tooth surfaces which may
have anti-bacterial activity like the saponins,
flavonoids, triterpenoids and tannins.21
Our study showed a significant reduction in gingival
and plaque scores in Ocimum sanctum, which can be
attributed to compounds isolated from Ocimum
sanctum extract. Civsilineol, civsimavatine,
isothymonin, apigenin, rosavinic acid and eugenol
were observed for their anti-inflammatory activity or
cyclooxygenase inhibitory activity.22,23 Singh24,Singh
and Majumdar25 in their study reported that the anti-
inflammatory effect of Ocimum sanctum may be due
to the variable amount of linoleic acid present in the
fixed oil which has the capacity to block both the
cyclooxygenase and lipoxygenase pathways of
arachidonate metabolism. Our results were in
accordance with the study done by Gupta et al 14 who
stated that Ocimum sanctum mouthrinse may prove
to be an effective mouthwash owing to its ability in
decreasing periodontal indices by reducing plaque
accumulation, gingival inflammation and bleeding
and has no side effect as compared to chlorhexidine.
However Carlos Alfredo Franco Neto et al26 revealed
no difference in the efficacy of 0.12 to 0.2%
chlorhexidine and reported that the former
concentration leads to less staining of teeth. Though
our study reported no staining of teeth with use of
0.2% chlorhexidine solution. Hosadurga et al27 used
2% tulsi (Ocimum sanctum) gel in chronic
periodontitis and showed significant anti-
inflammatory properties for a period of 24-48 hours
resulting in reduction of gingival inflammation and
reduced pocket depth. Agarwal et al 18 analyzed the
effect of various concentrations of the Ocimum
sanctum extract ranging from 0.5 to 10%, and it was
observed that a 4% concentration of the extract was
optimum as an antibacterial agent against bacterial
Assessment of 4% ocimum sanctum and 0.2% chlorhexidine irrigation as an adjunct to scaling & root planing in management of chronic periodontitis - a randomized controlled trial ___________________________________________________________________Gaur J et al.
J Dent Specialities.2015;3(2):146-149 149
pathogens of the oral cavity; thus, in the present
study, a concentration of 4% was used. Our study
also showed significant reduction in pocket depths
and gain in the clinical attachment levels over a 30
day period for both the test and the control groups,
though there was no significant differences seen
when intergroup comparison was done.(Table 1) The
results of the study indicated that irrigation with 4 %
Ocimum sanctum showed comparable results when
compared to 0.2% of Chlorhexidine gluconate.
CONCLUSION
Both the groups demonstrated reduction in clinical
parameters after 30 days from baseline. CHX group
depicted better results as compared to Tulsi. However
Tulsi can be recommended as a safe herbal
alternative for its appreciable clinical results and
absence of adverse effects.
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Singh R, Karim W. A randomized controlled clinical
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25. Singh S, Majumdar DK. Evaluation of anti-
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How to cite this article: Gaur J, Chandra J, Chaudhry S, Vaish S,
Dodwad V. Assessment of 4% ocimum sanctum and 0.2%
chlorhexidine irrigation as an adjunct to scaling & root planing in management of chronic periodontitis - a randomized controlled
trial. J Dent Specialities,2015;3(2):146-149.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest related to this study.
____________________________________________________________________Original Research
J Dent Specialities.2015;3(2):150-155 150
Effect of resilient liner on masticatory efficiency and general patient
satisfaction in completely edentulous patients
Nidhi Mangtani1, Rajath S Pillai2, Dinesh Babu B3, Veena Jain4
ABSTRACT Objectives: To assess the effect of resilient lined denture on patient masticatory
efficiency, general patient satisfaction and denture quality as compare to conventional
complete denture over a period of one year.
Material and methodology: A total of 28 completely edentulous patients (14 males and
14 females) aged 45 to 60 years, having well-formed ridges were selected following
iclusion exclusion criteria. These were divided into two equal groups, i.e. control
(provided conventional mandibular complete denture –group 1) and experimental
(provided mandibular denture lined with acrylic soft denture liner – group 2). All patients
were clinically evaluated to assess the denture quality, and administered questionnaires
for masticatory efficiency and patients general satisfaction level at three intervals i.e. one
month (T0), 6 months (T1) and 1 year post-insertion (T2).
Results: Statistical analysis for individual question for masticatory efficiency showed
significantly higher score (P<.05) at baseline for experimental group as compared to
control. While at six and twelve months time interval, significant differences (P<.05)
were noted for some questions only. Intra-group analysis showed masticatory efficiency
improved significantly over time in controls, while in experimental group masticatory
efficiency remained the same (p>.05) for almost all the questions. Patient general
satisfaction score at different time intervals for each question showed no significant
difference (P>.05) on inter-group comparison. Time dependant intra-group comparison
for patient general satisfaction score also showed no significant difference in scores for
almost all the questions for both the groups. Statistical analysis for denture quality
showed dentures in experimental group have significantly higher (P<.05) scores for
denture retention and condition of supporting tissue as compared to control group, while
with time denture quality decreased significantly in both the groups.
Conclusion: Dentures with soft liner provided better masticatory efficiency while it had
no effect on patient’s general satisfaction. Denture quality is better for one with soft liners
as compare to one without soft liner.
Keywords: Edentulism, Masticatory, Efficiency
INTRODUCTION
dentulism leads to significant functional
impairment, psychological and social changes in
the patients.1 The problems arising from edentulism
range from difficulty in chewing, to poor nutrition,
unaesthetic appearance, speech impairment, all
leading to a physical handicap.2,3 That finally effect
the general health as well.4,5,6
Currently there are different treatment modalities
available to treat edentulism depending on the oral
conditions, patient acceptability, affordability and the
clinician’s expertise. Conventional complete dentures
are used successfully but patients with badly resorbed
ridges with atrophic mucosa or sharp residual ridges
have difficulty wearing conventional complete
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denture and therefore require an alternate treatment
modality.7 Difficulties encountered in such patients
can be overcome with either implants or resilient
liners.8,9,10 Although, implants are highly effective,
they are not a viable solution for all edentulous
patients as bone quality, quantity, medical problem,
psychological and financial constraints play an
important role in the treatment plan. Resilient liners,
on the other hand, have fewer limitations, non-
surgical application and low treatment cost. Resilient
liners, because of their resilience, act as shock
absorbers and distribute functional stress, thus
making it comfortable for patient to wear the
prosthesis.11,12,13
Various studies have evaluated the effect of soft
liners on maximum bite force, masticatory
performance, electromyography of muscles involved,
stress distribution in denture supporting tissues,
patient satisfaction and comfort in order to prove
their advantages over the conventional heat activated
acrylic resin dentures but no definite consensus has
been achieved.14-21
1Ex Senior Resident, 2Senior Research Fellow, 3Ex Junior Resident, 4Professor,
Department of Prosthodontics, Center for Dental Education and
Research, All India Institute of Medical
Sciences, New Delhi-29
Address for Correspondence:
Dr. Veena Jain Professor
Department of Prosthodontics,
Center for Dental Education and Research, All India Institute of Medical
Sciences, New Delhi-29
Email: [email protected]
Received: 13/09/2015 Accepted: 28/09/2015
E
Effect of resilient liner on masticatory efficiency and general patient satisfaction in completely edentulous patients __________________________________________________________Mangtani N et al.
J Dent Specialities.2015;3(2):150-155 151
Studies have been undertaken to objectively evaluate
masticatory efficiency, but the literature is scanty
regarding subjective evaluation of satisfaction with
masticatory efficiency and general satisfaction with
resilient liner lined (RLL) complete dentures.
Since the success of any prosthesis not only depends
upon the quality of prosthesis but also on patient’s
perceived satisfaction with the prosthesis, measuring
the prosthetic outcome by questioning the patient
himself regarding his satisfaction seems to be more
meaningful and has been undertaken in the present
study.
MATERIAL AND METHODS
After obtaining the ethical clearance (IESC/T-
255.01.06.2012), a total of 28 completely edentulous
patients aged 45 to 60 years were selected
irrespective of gender. Patients having class I jaw
relation, edentulous from last 6 months, well-
developed edentulous ridges with firm mucosa were
selected. Patients suffering from any systemic
disorder that influence bone metabolism were
excluded.
Computer generated randomization table was use to
divide these patients in two equal (N=14) age- and
gender-matched groups, on the basis of mandibular
denture lined with resilient liner (experimental or
Group B) or without (control or Group A). All
patients were provided conventional maxillary
compete denture.
The bilaterally balance complete denture was
fabricated using standard technique, except one
modification at the time of mold packing viz. 2 mm
thick heat cure acrylic denture soft liner packed along
with heat cure acrylic resin in experimental group.
Data collection
Subjective evaluation of patient satisfaction with
masticatory efficiency was done using modified
questionnaire based on index by Pocztaruk and
Frasca(22) (Table 2). It consists of ten questions with
four responses; ‘Totally satisfied’, ‘Satisfied’, ‘Not
sure’, and ‘Dissatisfied’.
For evaluation of patients general satisfaction,
denture questionnaire based on index by Wolff et
al(23) consisting of seven questions was used (Table
3). Response for each question ranged from
‘Excellent’, ‘Good’, ‘Fair’, ‘Poor’, and ‘Intolerable’.
Both questionnaires were administered at three
intervals- baseline, 6 months and 1 year (T0, T1 and
T2, respectively) by a single evaluator. Mean scores
were calculated for each question in both
questionnaires for both groups.
All patients were evaluated clinically for the
assessment of denture quality (retention, stability,
support and occlusion) using rating legend given by
Woelfel(24). Two independent, calibrated
prosthodontists assessed the denture quality at three
different time intervals i.e. one month after denture
delivery (baseline, T0), 6 months (T1) and 1 year
post-insertion (T2). One-month time for adjustment
to new prosthesis was given to all patients prior to
data collection.
Statistical analysis
Patient generated responses from both the
questionnaires were compiled as numeric data.
Statistical Package for Social Sciences, Version 13.1
(IBM, Chicago, IL.) was used for all statistical
calculations. For both the questionnaires, individual
question scores were calculated and represented as
mean ± standard deviation. For each question, mean
score for controls was compared with experimental at
all intervals using non-parametric test (chi square
test) and p value less than 0.05 was considered
statistically significant. Repeated measures analysis
of variance was used for intra-group comparison of
mean scores at three time intervals for each question
(both the questionnaires) in both the groups.
Denture quality score for both groups (intra-group
comparison) over a period of 12 months (T0, T1, and
T2) were statistically analyzed by using non
parametric test i.e. Mann Whitney U test for
intergroup comparison and Friedman test for intra
group comparison.
RESULTS
Masticatory efficiency scores
Inter-group analysis for individual question of
masticatory efficiency questionnaire (Table 1)
showed that at baseline (T0), there was significant
differences (p<0.05) in scores for all questions with
better scores for Group B which showed patient
satisfaction in patients with soft liner.
At 6 month interval (T1), although mean satisfaction
scores for Group B were higher than Group A,
statistically significant difference was seen only for
some questions (Q5, Q6, Q7, Q8, and Q9). It could
be inferred that in response to satisfaction with eating
habits, chewing difficulty with any particular type of
food, and being embarrassed with eating food with
others, both the groups had similar experience.
At 12 month (T2) interval, again, the scores were
higher for Group B but statistically significant
difference (p<0.05) was only seen in response to
questions concerned with stability of dentures on
eating sticky food, difficulty with denture between
meals, force needed to swallow, need for special food
preparation and time taken to eat food. Satisfaction
scales were better for patients with soft liner for these
questions.
Intra-group comparison (Table 1) showed that for
Group A, there was statistically significant difference
(p<0.05) in scores for most questions over a period of
time from baseline to 6 months to 12 months with
overall improvement in scores.
Effect of resilient liner on masticatory efficiency and general patient satisfaction in completely edentulous patients __________________________________________________________Mangtani N et al.
J Dent Specialities.2015;3(2):150-155 152
For Group B, scores for most of the questions had no
significant difference (p>0.05) over time indicating
patient’s response to masticatory efficiency with soft
liner denture remains similar over a period of time
except for two questions pertaining to satisfaction
with eating habits as well as change on chewing with
artificial teeth compared to natural teeth. Scores for
both the question improved over time.
Patient’s general satisfaction scores
Inter-group comparison for each question’s score of
general patient satisfaction questionnaire at all the
three intervals (T0, T1, T2) showed that there was no
significant difference (p>0.05) which means similar
satisfaction levels between both groups (Table 2).
Intra-group comparison (Table 2) for Group A at
three intervals showed no significant difference
except question regarding comfort of lower denture.
Comfort with lower conventional denture in Group A
improved with time from 0- 6 months and remained
same from 6-12 months. Intra-group comparison
(Table 2) for Group B at three intervals showed no
significant difference except question regarding
chewing food well with denture. Patients in Group B
showed improved satisfaction with chewing food
with denture at 6 months compared to baseline.
Subjective evaluation of denture quality
The mean score of denture quality for all the
parameters decreased in both the groups with time;
while a significant decrease was found for
mandibular denture retention and tissue support only
(Table 3). Inter group comparison for denture quality
showed Group B patients had significantly higher
mandibular denture retention (at 6 and 12 month
periods only) and better lower tissue condition at all
the time intervals as compared to group A.
Table 1: Intra-group and inter-group comparison of mean score for each question of
masticatory efficiency questionnaires at three intervals. Question Group
A
p value (Intra-
group)
Group B
p value
(Intra- group)
T0
(A)
T0
(B)
P
value
T1
(A)
T1
(B)
P
value
T2
(A)
T2
(B)
P
value
Q1 Is there any change on
chewing with the
artificial teeth compared
with your natural teeth; is
it better now?
0.00* 0.007* 2.42 ± 0.51
3.35 ± 0.49
0.001* 3.21 ±
0.57
3.71 ±
0.46
0.064 3.21 ±
0.57
3.78 ±
0.42
0.026*
Q2 Are you satisfied with the
eating habits with the
artificial teeth?
0.008* 0.019* 2.71 ±
0.46
3.28 ±
0.61
0.030* 3.14
± 0.66
3.57
± 0.51
0.164 3.14
± 0.66
3.64
± 0.49
0.099
Q3 Are you feeling conscious
while having meals with
the denture?
0.00* 0.082 2.57 ± 0.64
3.42 ± 0.51
0.011* 3.21 ±
0.57
3.64 ±
0.49
0.131 3.21 ±
0.57
3.64 ±
0.49
0.131
Q4 Is there any difficulty in
chewing any type of food
with artificial teeth?
0.008* 0.336 2.42 ±
0.64
3.28 ±
0.46
0.009* 2.85
±
0.66
3.35
±
0.49
0.069 2.85
±
0.66
3.35
±
0.49
0.069
Q5 Is there a need for special
food preparation for you
to make chewing food
easier? [e.g. moistening,
pureeing, cutting into
small parts etc.]
0.010* 0.336 2.42 ±
0.66
3.28 ±
0.46
0.009* 2.78
± 0.57
3.35
± 0.49
0.036
*
2.92
± 0.47
3.35
± 0.49
0.088
Q6 How stable is your
denture on eating sticky
food?
0.015* 0.233 2.14 ± 0.66
3.42 ± 0.64
0.002* 2.57 ±
0.64
3.50 ±
0.65
0.007*
2.57 ±
0.85
3.57 ±
0.64
0.028*
Q7 Is there any force needed
to swallow the food?
0.070 0.336 2.78 ±
0.57
3.42 ±
0.64
0.032* 2.85
±
0.66
3.50
±
0.65
0.048
*
3.07
±
0.61
3.50
±
0.65
0.153
Q8 Have you ever faced any
difficulty with the denture
between meals?
0.869 0.233 2.85 ±
0.66
3.50 ±
0.51
0.033* 2.92
±
0.73
3.57
±
0.51
0.042
*
2.85
±
0.66
3.64
±
0.49
0.010
*
Q9 Compared with others, do
you feel you take a longer
time for chewing food?
0.021* 0.446 2.35 ±
0.49
3.28 ±
0.46
0.001* 2.71
± 0.72
3.35
± 0.49
0.019
*
2.78
± 0.69
3.42
± 0.51
0.029
*
Q10 Are you embarrassed on
having food with others?
0.155 0.336 2.71 ± 0.46
3.42 ± 0.51
0.006* 3.00 ±
0.55
3.50 ±
0.51
0.070 2.85 ±
0.66
3.50 ±
0.51
0.033*
T0: Baseline, T1: 6 months, T2: 12 months, * Significant
Effect of resilient liner on masticatory efficiency and general patient satisfaction in completely edentulous patients __________________________________________________________Mangtani N et al.
J Dent Specialities.2015;3(2):150-155 153
Table 2: Intra- and inter-group comparison of mean score for each question of patients’ general satisfaction
questionnaire at three intervals Question p value
(Intra-group)
T0 T0 P
value
T1 T1 P
value
T2 T2 P
value
Group
A
Group
B
Group
A
Group
B
Group
A
Gro
up B
Gro
up A
Gro
up B
Q1 Are you satisfied with
the appearance of your
denture?
0.999 0.999 4.07 ±
0.73
4.14 ±
0.53
0.433 4.07 ±
0.73
4.14
±
0.53
0.433 4.07
±
0.73
4.14
±
0.53
0.433
Q2 Does your upper denture
stay in place?
0.999 0.999 3.92 ±
0.82
4.00 ±
0.78
0.904 3.92 ±
0.82
4.00
± 0.78
0.904 3.92
± 0.82
4.00
± 0.78
0.904
Q3 Does your lower denture
stay in place?
0.999 0.999 3.14 ±
0.86
3.64 ±
0.92
0.528 3.14 ±
0.86
3.64
± 0.92
0.528 3.14
± 0.86
3.64
± 0.92
0.528
Q4 Can you chew your food
well with your dentures?
0.336 0.003* 3.21 ±
0.97
4.00 ±
0.78
0.117 3.28 ±
0.91
4.71
± 0.46
0.001
*
3.28
± 0.91
4.00
± 0.78
0.172
Q5 Are you satisfied with
how well you speak
with your dentures
0.999 0.999 3.42 ±
0.85
4.28 ±
0.61
0.055 3.42 ±
0.85
4.28
± 0.61
0.055 3.42
± 0.85
4.28
± 0.61
0.055
Q6 Is your upper denture is
comfortable?
0.103 0.165 4.50 ± 0.65
4.78 ± 0.42
0.373 4.70 ± 0.46
4.90 ±
0.26
0.326 4.70±
0.46
4.90 ±
0.26
0.326
Q7 Is your lower denture is
comfortable?
0.040* 0.999 3.64 ± 0.84
4.07 ± 0.82
0.311 3.92 ± 0.73
4.07 ±
0.82
0.659 3.92±
0.73
4.07 ±
0.82
0.659
T0: Baseline, T1: 6 months, T2: 12 months
* Significant
Table 3: Inter- and intra-group comparison of denture quality for different parameters. Group 1 (Mean ± SD) Group 2 (Mean ± SD) Inter-group P value*
Centric
Baseline 3.86 ± 0.36 3.93± 0.27 0.549
6 months 3.86 ±0.36 3.93 ±0.27 0.549
12 months 3.71 ±0.47 3.79 ±0.43 0.668
Intra-group P value# 0.135 0.135
Lower stability
Baseline 3.71 ±0.47 3.86 ±0.36 0.366
6 months 3.57 ±0.43 3.75 ±0.38 0.244
12 months 3.50± 0.48 3.71 ±0.38 0.230
Intra-group P value# 0.074 0.174
Lower retention
Baseline 3.54 ±0.60 3.82 ±0.37 0.131
6 months 3.25 ±0.58 3.79 ±0.43 0.011
12 months 3.14 ±0.41 3.54± 0.41 0.027
Intra-group P value# 0.002 0.012
Lower tissue condition
Baseline 2.79 ±0.43 3.86 ±0.36 0.000
6 months 2.71 ±0.47 3.86 ±0.36 0.000
12 months 2.29 ±0.47 3.43 ±0.51 0.000
Intra-group P value# 0.002 0.002
*Mann Whitney U test #Freidman test
DISCUSSION
Results of the study revealed patients having RLL
mandibular denture have better satisfaction with
masticatory efficiency at one month after denture
insertion. This can be explained by the reflex
controlled by the sensory input from the mucosa,
which may stop the closure of mandible to protect the
underlying mucosa from excessive pressure and
force. Patient wearing RLL mandibular denture,
experienced less pain and ulcers on the ridge in initial
phase of adjustment, therefore having longer
occluding phase of masticatory cycle and could apply
Effect of resilient liner on masticatory efficiency and general patient satisfaction in completely edentulous patients __________________________________________________________Mangtani N et al.
J Dent Specialities.2015;3(2):150-155 154
more amount of force, as resilient liners due to their
viscoelastic property absorb energy and prevent
transmission of forces to the underlying tissues.
Other different studies also showed better
masticatory efficiency scores (objective evaluation)
with RLL complete denture as compare to
conventional complete denture.14,16,17,18
At 6 months, patients with RLL denture found their
masticatory efficiency better than conventional group
in few aspects like a need for special food
preparation, better stability of denture on eating
sticky food, force needed to swallow the food,
difficulty with the denture between meals, and time
taken for chewing food. For remaining questions,
satisfaction level was similar. Previous studies too
showed patients with RLL denture have longer
occluding phase, can apply more force to chew the
food and have better retention and stability.14,17 At 12
months, patients showed further improvement in
masticatory efficiency. This may be due to the
development of skills to use the denture and
adaptation of the denture with the surrounding
tissues.17
Comparison of masticatory efficiency scores within
the group, over a period of time, revealed that
patients wearing conventional dentures showed
overall improvement in scores for most questions
over a period of 12 months, while patients with RLL
dentures showed almost no change in masticatory
efficiency with time. This indicates patients having
denture without resilient liner require longer
adaptation period as compare to those with RLL
dentures.
Individual question analysis for general patient
satisfaction showed that patients with RLL denture
have significant difference only for question relating
to chewing ability and comfort. While with regard to
esthetics, speaking, and retention of denture, patients
of both group had similar experience. This may be
due to the cushioning effect that RLL patients
experience, leading to less pain and discomfort
during the adaptation phase.14,16,18
Results of the current study for denture quality
showed retention of mandibular denture decreases
with time in both the groups but significantly more
reduction in controlled group. Similarly, condition of
supporting tissues was significantly affected with
time in both the groups but it was affected more for
control group. These changes may be due to time
dependent residual ridge resorption, wearing of teeth
and warpage of denture material.22,23 Fewer changes
in RLL denture may be due to their viscoelastic
nature- less forces are transmitted uniformly to the
underlying hard and soft tissues therefore lead to less
changes in underlying supporting tissues.24,25
CONCLUSION
In conclusion, patients wearing dentures with soft
liner were more satisfied with the masticatory
efficiency achieved than patients wearing
conventional complete denture. In regard to general
satisfaction with dentures (esthetics, speaking,
comfort, retention) both groups’ patients had similar
experience. Chewing ability was better in resilient
liner patients. Denture quality was better in resilient
liner group and decreased in both groups with time.
Based on the results obtained, further research on a
wider representative population needs to be
established.
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How to cite this article: Mangtani N, Pillai RS, Dinesh Babu B, Jain V. Effect of resilient liner on masticatory efficiency and
general patient satisfaction in completely edentulous patients. J
Dent Specialities, 2015;3(2):150-155.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
____________________________________________________________________Original Research
J Dent Specialities.2015;3(2):156-158 156
Computed tomography scan evaluation of adequacy for reduction of
zygomatic arch fracture using Gillie’s temporal approach
Rajratna Manikrao Sonone1, Sanjeev Kumar2, Pankaj Kukreja3, Anuja Agarwal4, Alok Bhatnagar 5, Vidhi Chhabra6
ABSTRACT Aim: The zygomatic bone is the key component of the structural facial aesthetics as it
constitutes the prominence of the cheek bone. Also, the most frequent clinical findings in
zygomatic arch fracture includes limitation of jaw movement and flattening of cheek. So
it is necessary to elevate the arch precisely. Therefore, a prospective study was conducted
toevaluate adequacy for reduction of zygomatic arch fracture using Gillie’s temporal
approach with the help of pre-operative and post-operative CT scan.
Materials & methods: 4 patients, who received surgical treatment of zygomatico-
maxillary complex (ZMC) fractures at the Department of Oral and Maxillofacial Surgery
were examined for displacement of zygomatic arch pre-operatively with CT scan then re-
evaluated the same site post-operatively.
Results: The pre-operative mean displacement at the zygomatic arch, in millimetres
(mm), was M = 2.8, SD = 3.011. After reduction, the post-operative displacement was M
= 0.4, SD = 0.699. The percentage of reduction was M = 85, SD = 24.15.
Conclusion: Gillie’s temporal approach for zygomatic arch fracture reduction is precisely
considerable due to its simple and effective method and cosmetically more acceptable.
Keywords: Zygomatic fractures, Zygomatico-maxillary complex, Fracture
INTRODUCTION
ace being the most important part of aesthetic
concern in the human body is prone for fractures
due to road traffic accidents, physical assaults, sports
injuries, industrial accidents and so on. Zygomatic
fracture management was revolutionized with the
advent of internal fixation with wires in 1942. In
1978, Champy’s et al proposed the adaptation
osteosynthesis with plate and screw fixation. In the
early part of twentieth century, different approaches
to the zygomatic bone were established and reduction
of the fracture without fixation was described.1
Gillie’s temporal approach was first reported in 1927
by Gillie, Kilner and Stone. It was frequently used
because of the short duration of general anaesthesia
and minimal morbidity. The advantages of this closed
approach are short duration of anaesthesia, decreased
possibility of facial nerve damage, decreased indirect
trauma to the globe, absence of visible scar.2
MATERIALS & METHODS
This study was conducted in the Department of Oral
and Maxillofacial Surgery at I.T.S. Centre for Dental
Studies and Research, Muradnagar, Ghaziabad,
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Website:
www.its-jds.in
DOI: 10.5958/2393-9834.2015.00006.6
Uttar Pradesh. The study was undertaken for a period
of one year and six months i.e. from October 2012 till
April 2014. Patients with only Zygomatico maxillary
fractures were included. All the cases were treated
under general anaesthesia. Pre anaesthetic concern,
neurology and ophthalmology opinions were
obtained for all the cases. Following inclusion and
exclusion criteria was followed:
Inclusion criteria: 1. Fracture through anterior orbital rim and
orbital floor,
2. Postero-lateral wall of maxillary sinus,
3. Zygomatic arch,
4. Zygomatico frontal suture.
Exclusion criteria: 1. Undisplaced ZMC fractures
2. Comminuted ZMC fractures
3. Medically compromised patients who could
not be operated under General Anesthesia.
(ASA III and above) as described by the
American Society of Anesthesiologists’ (ASA)
classification of Physical Health, 2011.3
All the patients were sent for pre-operative computed
tomography examination which included axial,
coronal and sagittal sections with 2 mm slice
thickness. A single 3rd generation CT machine was
used throughout the study for all the radiographic
examinations, which had an aperture of 70
centimetres, maximum scan view of 50 centimetres,
1PG Student, 2Professor and Head, 3Associate Professor 4 Professor
5,6Senior Lecturer
Department of Oral and Maxillofacial
Surgery,
ITS-CDSR, Muradnagar, Ghaziabad
Address for Correspondence:
Dr. Rajratna Manikrao Sonone,
PG Student, Dept. of Oral and Maxillofacial Surgery. I.T.S-Centre for
Dental Studies & Research,
Ghaziabad E-mail: [email protected]
Received: 24-10-2014
Accepted: 26-03-2015
F
Computed tomography scan evaluation of adequacy for reduction of zygomatic arch fracture _________________________________________________________________Sonone RM et al.
J Dent Specialities.2015;3(2):156-158 157
generator power rating of 40 kilowatt and an Ultra
Fast Ceramic (UFC) detector
Gillie’s temporal approach
After intubation, identification of superficial
temporal artery was done, surface markings were
carried out with the help of surgical marking pen on
temporal region according to Gillie’s technique
which describes a temporal incision 2 cm in length,
made 2.5 cm superior and anterior to the helix, within
the hairline. After local infiltration, short oblique
incision was made in the temporal area with the help
of 15 numbers B.P. blade above the middle of the
zygomatic arch.4 The incision was dependent to the
temporalis fascia and the margins were somewhat
undermined. The fascia was incised, taking care not
to damage underlying muscle. A suitable instrument,
like a Rowe zygomatic arch elevator or a strong
periosteal elevator was inserted under the fascia and
advanced towards and under the displaced bone
fragment to reduce the displaced arch (Figure-15).
An audible click and fullness of the cheek together
with palpation for normal contour of the zygomatic
bone gave an idea about the adequacy of the
reduction. The wound was closed in two layers:
fascia with Vicryl, and skin with Prolene.5,6
Fig. 1: Pre-operative CT scan of left zygomatic
arch fracture
Fig. 2: Post-operative CT scan of left zygomatic
arch fracture
RESULTS
The pre-operative mean displacement at the
zygomatic arch, in millimetres (mm), was M = 2.8,
SD = 3.011, SE = 0.952, MIN = 0 mm, Q1 =0.5,
MED = 2, Q3 = 4, and MAX = 10. After reduction,
the post-operative displacement was M = 0.4, SD =
0.699, SE = 0.221, MIN = 0 mm, Q1 = 0, MED = 0,
Q3 = 0.75, and MAX = 2. The percentage of
reduction was M = 85, SD = 24.15, SE = 7.637, MIN
= 50, Q1 =62.5, MED = 100, Q3 = 100, and MAX =
100. Upon comparison between the two by Wilcoxon
Signed-ranks test (two-tailed), it was found that
reduction achieved was statistically significant
(p<0.05), Z = -2.379, p = 0.17, indicating that the
current technique followed gives adequate reduction
and fixation of the fracture at the zygomatic arch.
Fig. 3: Pre-operative and post-operative CT
displacement in mm zygomatic arch
DISCUSSION
Zygomatic arch is formed by the temporal process
ofzygoma and the zygomatic process of temporal
bone.The masseter muscle consisting of three
superimposedlayers which blend anteriorly gains
attachment fromzygoma and the zygomatic arch. The
superficial layerarises from the maxillary process of
zygomatic boneand from the anterior two-third of the
lower border ofthe zygomatic arch.7 The middle layer
arises from thedeep surface of the anterior two-third
of the zygomatic arch. The deep layer arises from the
deep surface of thearch. Contraction of this muscle is
often implicated asthe primary cause of post
reduction displacement of the zygoma. Due to the
attachment of the temporalis fasciaalong the superior
aspect of the arch, internal fixationis unnecessary
even in mildly displaced fractures asthe fascia will
immobilize the fragments effectively.7,8
The transoral (Keen’s) approach provides the most
directaccess to the zygomatic arch. It allows for an
intraoralincision, and therefore does not have the risk
of scaralopecia that will result from a temporal
(Gillie’s) approach. However, they may result in
increasedrates of infection by introducing oral flora
0
2
4
6
8
10
12
ZYGOMATIC ARCH (displacement in mm)
Pre-operative Post-operative
Computed tomography scan evaluation of adequacy for reduction of zygomatic arch fracture _________________________________________________________________Sonone RM et al.
J Dent Specialities.2015;3(2):156-158 158
into the infratemporal fossa. Gilles et al. described
the temporalfossa approach in 1927, and this became
a very popularmethod for the treatment of isolated
arch fractures3. This procedure has advantages in that
it leaves no facialscars and is simple to perform. The
temporal (Gillie’s) approach which is open approach
can be considered forthe reduction of the zygomatic
arch.8
The fracture of the zygomatic arch bone can result in
restricted mouth opening due to impingement on
thecoronoid process. Disruption of the zygomatic
position also carries psychological, aesthetic and
functional significance, causing impairment of ocular
and mandibular function. Therefore, for both
cosmetic and functional reasons, it is mandatory that
zygomatic bone injury is properly diagnosed and
adequately managed. Kaastad E, Freng A who also
used Gillie’s temporal approach and found
satisfactory results.9 Gillie’s approach was also the
principle technique of reduction used by Balle V et al
which is in accordance with our study.10 Kamath RA
et al also used Gillie’s procedure for reduction and
proved it to be successful for adequate reduction and
fixation of ZMC fractures.11
The slice thickness of 2mm was kept during CT
scanning for every case both pre and post-operative
CT scanning. This is in accordance with study done
by Zilka A and Chales JS et al who recommended
thin slices (2-3mm) because that would decrease the
time of scanning and the risk of radiation.12,13 Cheon
SJ et al have stated that Gillie’s approach is a
promising method as it gives relatively acceptable
post-operative facial symmetry and a decrease in the
temporal protrusion.14 The probable reason for good
reduction at zygomatic arch region other than the
regions involved in zygomatico-maxillary complex
fracture is that it has certain advantages, such as
direct elevation of the arch with the help of elevator
and confirmation of reduction with tactile sensation.
Till date Gillie’s approach holds the best procedure
for the elevation of fractured zygomatic arch.
CONCLUSION
Thus, we conclude that Gillie’s approach for
zygomatic arch fracture reduction is precisely
considerable due to its simple and effective method
and cosmetically more acceptable and CT scan
evaluation provides us the vision of best reduction
achieved.
REFERENCES 1. Priya S, Ebenezerr V, Balakrishnan R. Versatility
of Gillie’s temporal approach in the management
of ZMC fractures. Biomed Pharma J 2014;7:253-6.
2. Gillies HD, Kilner TP, Stone D. Fractures of the
malar-zygomatic compound with a description of a
new X-ray position. Br J Surg. 1927;14:651-3.
3. Daabiss M. American Society of Anesthesiologists
physical status classification, Indian J Anaesth.
2011;55:111–15.
4. Adam AA, Zhi L, Bing LZ, Zhong Xing WU.
Evaluation of treatment of zygomatic bone and
zygomatic arch fractures: a retrospective study of
10 years. J Maxillofac Oral Surg. 2012;11:171-76.
5. Gillies H D, Kilner T P and Stone D. Fractures of
the malar-zygomatic compound with a description
of a new X-ray position. Br J Surg. 1927;14:651-54.
6. Swanson E, Vercler C, Yaremchuk MJ, Gordon CR.
Modified Gillies approach for zygomatic arch
fracture reduction in the setting of bicoronal
exposure. J Craniofac Surg. 2012;23:859-62.
7. Carter TG, Bagheri S, Dierks EJ. Towel Clip
Reduction of the Depressed Zygomatic Arch
Fracture. J Oral Maxillofac Surg. 2005; 63:1244-6.
8. Czerwinsk M, Ma S and Williams HB. Zygomatic
Arch Deformation: An Anatomic and Clinical
Study. J Oral Maxillofac Surg. 2008;66:2322-9.
9. Kaastad E, Freng A. Zygomatico-maxillary
fractures. Late results after traction-hook reduction.
J Craniomaxillofac Surg. 1989;17:210-4.
10. Balle V, Christensen PH, Greisen O, Jørgensen PS.
Treatment of zygomatic fractures: a follow-up study
of 105 patients. Clin Otolaryngol Allied Sci.
1982;7:411-16.
11. Kamath RA, Bharani S, Hammannavar R, Ingle
SP, Shah AG. Maxillofacial trauma in central
karnataka, India: an outcome of 95 cases in a
regional trauma care centre. Craniomaxillofac
Trauma Reconstr. 2012;5:197-04.
12. Zilka A. Computed tomography in facial trauma.
Radiology. 1982;144:545-8.
13. Chales JS, Terry SB. Normal CT anatomy of the
paranasalsinuses. Radiol Clin North Am. 1989;
22:107- 18.
14. Cheon JS, Seo BN, Yang JY, Son KM. Clinical
Follow-up on Sagittal Fracture at the Temporal
Root of the Zygomati Arch: Does It Need Open
Reduction? Arch Plast Surg. 2013;40:546-52.
How to cite this article: Sonone RM, Kumar S, Kukreja P,
Agarwal A, Bhatnagar A, Chhabra V. Computed tomography scan
evaluation of adequacy for reduction of zygomatic arch fracture
using gillie’s temporal approach.J Dent Specialities,2015;3(2):156-
158.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
____________________________________________________________________Original Research
J Dent Specialities.2015;3(2):159-163 159
Risk of bleeding in patients with cardiovascular disease on aspirin
undergoing tooth extraction
Anand Mangalgi1, Aafreen Aftab2, Santosh Mathpathi3, PavanTenglikar4, Swati Devani5, Nagesh Ingleshwar6
ABSTRACT Background and purpose: Aspirin is the most frequently used preventive and
therapeutic drug for patients with cardiovascular diseases because of its antiplatelet
property, which might lead to the risk of excessive bleeding during the surgery. The
purpose of the study is to analyze if there is a need to discontinue low dose antiplatelet
therapy before dental extraction.
Methodology: The study samples consisted of 25 patients receiving 100 milligrams of
aspirin daily and were scheduled to undergo dental extractions. Each patient acted as a
control for himself, wherein an extraction was performed on a patient when aspirin was
not discontinued and a second extraction after discontinuing aspirin for 72 hours prior
the procedure. The bleeding time, clotting time, platelet count and INR were measured
preoperatively at both the appointments and the amount of blood loss during the
procedure was assessed.
Results: The mean blood loss at the first appointment for the patients was 5.78 ml while
it was 1.18 ml at the second appointment. The difference was statistically significant
with a t – value of 3.2. However, the blood loss in patients during the first appointment
was easily managed using local hemostatic measures which prevent any grave bleeding
complication.
Conclusion: From the observation in this study it can be stated that the low dose aspirin
therapy can be continued prior to extraction procedure in the oral cavity without the fear
of excessive intra-operative and post operative bleeding.
Key words: Cardiovascular Disease, Aspirin, Tooth Extraction, Blood Loss
INTRODUCTION
n the modern era, a majority of the population in
the age group of 50 and above shows a tendency
towards developing cardiovascular disease, mainly
due to imbalanced diet and a lack of physical activity.
These patients are usually on aspirin therapy that
helps prevent the thromboembolic events to which
these patients are susceptible. Aspirin, Acetyl
Salicylic Acid (ASA), irreversibly inhibits the
enzyme cyclooxygenase-1 thereby leading to the
blockage of the synthesis of thromboxane A2 whichis
required for platelet aggregation.1 Thus aspirin exerts
its antiplatelet activity by preventing platelet
aggregation and thereby avoiding thrombus
formation within the blood stream. This prevents
episode of thrombosis and vascular ischemic events.2
The dental management of these patients, who
require an extraction of tooth is an issue of concern,
as the aspirin may lead to intra operative
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DOI: 10.5958/2393-9834.2015.00007.8
and post operative uncontrolled excessive bleeding
due to its anti platelet action. But altering the dosage
or discontinuing it 7-10 days prior to the procedure
may predispose the patient to an increase risk of
developing an myocardial infarction or stroke, which
is life threatening.3 Few authors have established that
the aspirin therapy in patients with cardiovascular
diseases need not be discontinued and dental
procedures like simple extractions may be performed
without the fear of excessive bleeding intra-operative
or post-operatively.
This study intends to evaluate the need to discontinue
the low dose aspirin prior to dental extraction in
patients with cardiovascular disease by comparing
the net blood loss and evaluating the effectiveness of
local hemostatic procedures to avoid excessive
bleeding during and after the procedure in a patient
with and without discontinuation of aspirin.
PATIENTS AND METHODS
Twenty five patients presenting to the oral and
maxillofacial surgery OPD, diagnosed with chronic
generalized periodontitis and giving a history of
cardiovascular diseases, receiving 100 mg of aspirin
daily were included in the study. All subjects were
advised for multiple mandibular molar tooth
extraction. Written informed consent and physician
1Senior lecturer, 2Post Graduate,
Department of Oral and Maxillofacial
Surgery, 5,6Senior lecturer, Department of
Prosthodontics,
HKE’S S. Nijalingappa Institute of
Dental Sciences & Research, Gulbarga 3Senior Lecturer, Oral and Maxillofacial
Surgery, A.M.E's dental college, Raichur 4Senior Lecturer, Oral and Maxillofacial
Surgery, HKDET's Dental College and
Hospital, Humnabad
Address for Correspondence:
Dr. Anand Mangalgi Senior lecturer, Department of Oral and
Maxillofacial Surgery, HKE’S S. Nijalingappa Institute of
Dental Sciences &Research,
Sedam road, Gulbarga, Karnataka, India- 585105
E-mail: [email protected]
Received: 20/03/2015
Accepted: 15/06/2015
I
Risk of bleeding in patients with cardiovascular disease on aspirin undergoing tooth extraction ________________________________________________________________________Mangalgi A et al.
J Dent Specialities.2015;3(2):159-163 160
opinion was taken from every patient prior to their
inclusion in the study and ethical clearance was
achieved from the national research committee. Each
patient acted both as a control as well as a case for
the study.
Inclusion Criterion-
1. Patients in the age group of 55-75 years
were included in the study
2. Tooth included were mandibular molars
3. Extraction of teeth for chronic generalized
periodontitis where other restorative
procedures were not possible and indicated
for extraction.
4. Grade 1 hypertensive patients
Exclusion Criterion-
1. Patients on anticoagulants like heparin,
warfarin sodium.
2. Patients on any other antiplatelet therapy.
3. Patients on steroids, hormonal therapy and
any drug that interacts with antiplatelet
drugs.
4. Patients suffering with diabetes mellitus.
5. Anemic patients.
6. Non-alcoholics, Non-smokers.
7. Patients with any other bleeding disorders.
8. Patients having hepatic and renal
dysfunction.
Prior to fixing an appointment, the blood pressure
was recorded and bleeding time, clotting time,
platelet count and INR were assessed. Only after
reports obtained were within normal limits, the
patients were prescribed antibiotics in accordance to
AHA guidelines in order to preventsubacute bacterial
endocarditis.4 (Table 1) the patient was then subjected
to extraction of single mandibular molar tooth.
Intra operative bleeding was effectively controlled by
local haemostatic procedures such as pressure pack
and suture application. The amount of blood loss
during the procedure was estimated. Thirty minutes
post procedure, the operated site was checked for any
ooz or bleed. The patient was prescribed paracetemol
500 mg TID along with prophylactic antibiotics
prescribed earlier and was advised to discontinue
aspirin for a period of three days and return on the
fourth day, for extraction of the other mandibular
molar.
The procedure was done by the same operator and the
amount of blood loss during the procedure was
estimated along with the effectiveness of local
hemostatic procedure. A comparison between the
blood losses as well as the effectiveness of local
hemostatic procedure to prevent bleeding in both
appointments was done.
Surgical Procedure:
All the extractions were performed by the same
surgeon on an outpatient basis under local anesthesia
using plain 2% lignocaine hydrochloride. The use of
suction was avoided during the procedure to allow an
accurate estimate of the blood loss. The surgical field
was kept clear of blood with gauze. Saliva
contamination was avoided by placing gauze in the
sub mandibular and parotid duct regions.
An electronic weighing scale was used to weigh the
surgical gauze pre-operatively. Post operatively, the
blood soaked gauze was weighed immediately to
avoid the loss by evaporation. It is customarily
assumed that 1 ml. of blood weighs 1 gram.[5]
Therefore the calculated difference of weight
between the gauze preoperatively and post-
operatively was converted directly to a volume
measurement of blood loss.
A figure of eight suture was placed at the surgical site
with 3/0 black braided silk and a pressure pack with a
sterile gauze was placed for 30 minutes and re
assessed for bleeding. Local hemostatic agents were
kept ready to control any untoward bleeding
encountered.
On comparing the control of blood loss between both
the appointments of a single patient, it was observed
that there was no need for an additional local
hemostatic measure in the first appointment and
bleeding was very well controlled as it was in second
appointment wherein the patient was asked to
discontinue aspirin intake 72 hours prior to operative
procedure. Patients were discharged after giving strict
post-extraction instructions. Patients were followed
up for 24, 48 and 72 hours after extraction of teeth
for possible bleeding episodes and there were no
reported bleeding episodes.
RESULTS
The mean blood loss at the first appointment for the
patients was 5.78; with a standard deviation of 5.46,
whereas it was 1.18 with a standard deviation of
1.13ml. The difference was statistically significant
with a t – value of 3.21 inferring that a increased
amount of bleeding was noted at the first
appointment as compared to the second appointment
in the same patient. (Table 2)
The mean bleeding time at first appointment was
found to be 130.8 seconds with a standard deviation
of 17.59 which was slightly increased as compared to
the mean bleeding time of 114.6 seconds with
standard deviation of 18.11 at second appointment
where aspirin was discontinued, which was
statistically significant with a t – value of 4.23.
(Table 3) The mean INR recorded at first
appointment was 1.18 +/- 0.25 in contrast to the mean
INR of 1.08 +/-0.10 which was observed in each
patient after discontinuing aspirin prior to extraction
procedure, which was also statistically significant
with a t-value of 3.14. (Table 4)
However, the clotting time and platelet count were
within normal range and the difference between both
groups was not statistically significant.
Risk of bleeding in patients with cardiovascular disease on aspirin undergoing tooth extraction ________________________________________________________________________Mangalgi A et al.
J Dent Specialities.2015;3(2):159-163 161
Table 1: AHA guidelines for prevention of subacute bacterial endocarditis
Situation Agents Adult Dosage (Single Dose
30 to 60 min Before
Procedure)
Oral Amoxicillin 2 gram
Unable to take oral
medication
Ampicillin OR
Cefazolin or ceftriaxone
2 g IM or IV
1 g IM or IV
Allergic to penicillins—oral Cephalexin OR
Clindamycin OR
Azithromycin or
clarithromycin
2 g
600 mg
500 mg
Allergic to penicillins and
unable to take oral
medication
Cefazolin or ceftriaxone
OR Clindamycin
1 g IM or IV
600 mg IM or IV
Table 2: Comparison of mean blood loss at both appointments
Mean blood loss
(in ml)
Standard deviation Range
Patients on aspirin (1st
appointment)
5.78 5.46 3.03- 7.66
Patients discontinued
aspirin (2nd appointment)
1.18 1.13 4.03-6.95
Table 3: Comparison of mean bleeding time at both appointments
Mean Bleeding
time (in seconds)
Standard
deviation
Range
Patients on aspirin (1st
appointment)
130.8 17.59 105- 165
Patients discontinued
aspirin (2nd appointment)
114.6 18.11 85- 150
Table 4: Comparison of mean INR at both appointments
Mean INR
(in seconds)
Standard
deviation
Range
Patients on aspirin (1st
appointment)
1.18 0.25 1.00- 1.35
Patients discontinued aspirin
(2nd appointment)
1.08 0.10 1.00- 1.30
DISCUSSION
The management of a patient on aspirin therapy for
cardiovascular diseases who have to undergo oral
surgical procedures is a topic of concern to the oral
surgeon as there is a potential risk for excessive
bleeding after a surgical procedure, even if it is an
uncomplicated extraction of teeth. This is attributed
to the antiplatelet action of aspirin.5
Aspirin even at low doses of about 0.5-1mg /kg per
day tends to inhibit platelet function for the entire
lifespan of the platelet which is approximately 10
days.6
This is used to an advantage by a physician to
prevent intravascular thrombosis without eliciting the
possible side effects of high doses of aspirin.
The decision to continue or discontinue is like
weighing the risk of any possible thromboembolic
event against the risk of bleeding during the surgical
procedure. Few factors such as patient’s inheritent
risk factors for bleeding, additional ongoing
treatment which increases the bleeding risk, invasive
potential of the surgical procedure and potential risk
of thromboembolic event should be considered
before stopping antiplatelet therapy.7
In the comparison of the net blood loss during
extraction of teeth in a patient in whom extraction
Risk of bleeding in patients with cardiovascular disease on aspirin undergoing tooth extraction ________________________________________________________________________Mangalgi A et al.
J Dent Specialities.2015;3(2):159-163 162
was done without discontinuation of aspirin and after
discontinuation of aspirin for a period of three days,
it was observed that, the intra-operative blood loss
was more in the initial appointment where aspirin
was made to continue. Also the bleeding time and
INR were slightly increased in the initial appointment
as compared to second appointment where the patient
was asked to discontinue aspirin intake. During both
the appointments, no patient showed any
postoperative bleeding episodes. The method of
weighing surgical gauze for measuring the intra-
operative blood loss during the appointments, though
not very accurate is relatively easy and commonly
used to calculate blood loss and definitely allows a
better assessment of blood loss as compared to
suction devices.8
Several authors have advocated the practice of
discontinuation of aspirin prior to oral surgical
procedure to avoid the risk of excessive bleeding
intra-operatively and post operatively. While a few
authors recommended the discontinuation for seven
to ten days prior to the procedure, many other are of
the opinion that discontinuation of aspirin three days
prior to the procedure is justified.1 In contrast to this
practice it is proposed by a few authors that, the
discontinuation of aspirin is unwarranted prior to
minor oral surgical procedures, as the aspirin slightly
increase bleeding in oral surgical procedure which
can be controlled by local haemostatic measures.9 In
our study we observed well controlled bleeding when
a patient was on aspirin and when the same patient
discontinued aspirin. The results obtained in this
study are in concordance with the opinion that the
minor oral surgical procedures may be carried out
without the discontinuation of aspirin.
It is reported that, extraction of periodontally
involved teeth evokes increased bleeding both intra-
operatively and post operatively as compared to
extraction of carious teeth in a patient on aspirin
therapy. This has been attributed to the hyperemic
condition of the gingiva along with possible fragility
of blood vessels leading to the bleeding.10 The patient
inherent factors such as older age, male gender,
systemic conditions like diabetes mellitus and
hypertension may be considered as risk factors for
increased bleeding.3 Also the number of teeth to be
extracted in such patients in each appointment has a
role in the loss of blood and has to be taken into
consideration.
The hyper responsiveness of few individuals to
aspirin therapy has been demonstrated by Ardekian et
al; who observed prolonged bleeding episodes in six
patients, 4 patients who continued asprin and 2
patients who discontinued aspirin after extraction of
whom, 10% TAE and antifibrinolytic agents had to
be used to bring about a control on the bleeding.11
These patients were assumed to be hyper responsive
to asprin as compared to other patients on aspirin
therapy taking the same dosage. The identification of
these hype responders to aspirin is essential for which
a platelet function testing algorithm that combines
preoperative risk factor assessment, template
bleeding time and flow cytometry has been
proposed.12
It is observed in this study that a low dose of aspirin
(<325mg/day) need not be discontinued prior to
routine oral surgical procedures as the risk of
postoperative bleeding is minimal. Extensive surgical
procedures may require the discontinuation of aspirin
for a period of up to three days prior to the procedure.
CONCLUSION
This study demonstrated that extraction of teeth in
patients on low dose of aspirin did not cause
significant intra operative or post operative bleeding.
Discontinuation of aspirin increases the risk of
thromboembolic events which leads to high
morbidity rate of such patients. The cardioprotective
benefits of aspirin outweigh the risk of oral bleeding,
which can be effectively controlled by local
hemostatic measures. Hence it is advisable and safe
to continue low dose aspirin therapy (100mg/day)
when routine dental extractions are performed.
REFERENCES 1. Ahmed N, Lashmi D, Nazar N. Aspirin and dental
extraction: Still a myth? Int J Pharm Clin Res.
2015;7:109-12.
2. Madhulaxmi M, Wahab A. Can aspirin be continued
during dental extraction? Int J Pharm PharmSci. 2014;
6:20-23.
3. Verma G. Dental extraction can be performed safely in
patients on aspirin therapy: A Timely reminder. ISRN
Dent. 2014 Apr 1;2014:463684. doi:
10.1155/2014/463684. eCollection 2014.
4. Wilson W, Taubert KA, Gewitz M, Lockhart PB,
Baddour LM, Levison M, Bolger A, Cabell CH,
Takahashi M, Baltimore RS, Newburger JW, Strom
BL, Tani LY, Gerber M, Bonow RO, Pallasch T,
Shulman ST, Rowley AH, Burns JC, Ferrieri P,
Gardner T, Goff D, Durack DT. Prevention of
Infective Endocarditis: Guidelines from the American
Heart Association. Circulation. 2007;116:1736-54.
5. Thornton JA. Estimation of blood loss during surgery.
6. Krishna B, Nithin A, Alexander M. Extraction and
antiplatelet therapy. J. Oral Maxillofac Surg.
2008;66:2063-66.
7. Bertrand ME. When and how to discontinue
antiplatelet therapy. European Heart J Supplements.
2008;10:p A35-A41.
8. John HC, Fernando A, Murray RA. Anticoagulation
and minor oral surgery: Should the anticoagulation
regimen be altered. J Oral Maxillofac Surg.
2000;58:131-35.
9. Nasser N. The effect of aspirin on bleeding after
extraction of teeth. Saudi Dent J. 2009;21: 57-61.
10. Lillis T, Ziakas A, Koskinas K, Tsirlis A, Giannoglou
G. Safety of dental extraction during interrupted single
or dual antiplatelet treatment. Am J Cardiology.
2011;108:964-67.
Risk of bleeding in patients with cardiovascular disease on aspirin undergoing tooth extraction ________________________________________________________________________Mangalgi A et al.
J Dent Specialities.2015;3(2):159-163 163
11. Ardekian L, Gaspar R, Peled M, Brener B, Laufer D.
Does low dose aspirin therapy complicate oral surgical
procedure? J Am Dent Assoc. 2000;131:331-35.
12. Ferraris VA, Ferraris SP, Joseph O, Wehner P,
Mentzer RM. Aspirin and Postoperative Bleeding
After Coronary Artery Bypass Grafting. Annals Surg.
2002;235:820-27.
How to cite this article: Mangalgi A, Aftab A, Mathpathi S, Tenglikar P, Devani S, Ingleshwar N. Risk of bleeding in patients
with cardiovascular disease on aspirin undergoing tooth extraction.
J Dent Specialities, 2015;3(3):1-3.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
____________________________________________________________________Original Research
J Dent Specialities.2015;3(2):164-169 164
Comparative analysis of post operative analgesic requirement in
patient undergoing minor oral surgery using buprenorphine
with lignocaine versus lignocaine - a double blind study
Himanshu Thukral1, Sukumar Singh2, Anuja Aggrawal3, Sanjeev Kumar4, Vijay Mishra5, Kumar Rakshak Anand6
ABSTRACT
Aim: The aim of this study is comparative analysis of post operative analgesic
requirement in patient undergoing minor oral surgery using 2% Lignocaine with
1:200000 Adrenaline and Buprenorphine versus 2% lignocaine with 1:200000
Adrenaline.
Materials and Method: One hundred patients requiring minor oral surgery were
included in the study. The patients were randomized by a third party and allocated to
one of the two study groups. This allowed the patients and the operators to remain
unaware of the group allocations. 1 ml of Buprenorphine Hydrochloride injection I.V
which contains an equivalent of 0.3 mg Buprenorphine was withdrawn into a syringe
and injected into a 30 ml vial of 2 % Lignocaine with Adrenaline 1:200000. Thus each
ml of local anesthetic contained 0.01 mg of Buprenorphine. This solution was labelled
and used for the study.
Results: The duration of analgesia in Group I was found to be 13.71 ± 7.2 h and Group
II was 39.58 ± the average consumption of NSAIDs was found to be 2.88 as compared
to Group II mean value of 1.29 (P=0.0001).
Conclusion: We concluded that addition of 0.3 mg of Buprenorphine to 30 ml
Lignocaine with Adrenaline 1:200000 for minor oral surgery results in significant
improvement in postoperative analgesia up to 39 h and markedly reduces the need for
excessive analgesic intake. Thus reducing the adverse effects associated with excessive
use of NSAIDs. Further studies needs to be done as there is less literature about
Buprenorphine added to local anaesthetist.
Keyword: Buprenorphine, Hydrochloride, Analgesia
INTRODUCTION
ain is an unpleasant emotional experience usually
initiated by a noxious stimulus and transmitted
over a specialised neural network to the central
nervous system where it is interpreted as such.1 After
noxious stimuli prostaglandins are released from cell
membrane through cyclo-oxygenase pathway and
they mediate inflammation and inflammatory induced
pain. In most cases pain reaction threshold is lowered
by fear, apprehension, fatigue and emotional stress.
Centuries ago opium was determined to be “GOD’S
OWN MEDICINE” which produced definite
analgesic effect and also eliminated fear, anxiety and
suffering. Buprenorphine, first synthesized in 1966,
is a semisynthetic, oripavine alkaloid derived from
thebaine and binds to all three receptors.2
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Buprenorphine is highly lipophilic and is better
diffused into the perineurium.2,3 It produces longer
effect of analgesia compared to Morphine and
sufentanil. It is at least 30 times more potent than
Morphine Sulphate and has substantially longer
duration of action. This prolonged duration appears to
be because Buprenorphine seems to dissociate very
slowly from opioid receptors, so the usual duration of
action is about eight hours after parenteral
administration.4,5 Few studies have been conducted in
past which prove the efficacy of Buprenorphine in
Bupivacaine as a post operative analgesic in minor
oral surgery.3 Bupivacaine has longer duration of
action itself so it is difficult to analyse whether post
operative analgesic effect in minor oral surgical
procedure is due to the effect of Bupivacaine or
Buprenorphine. Kumar SP and colleagues compared
the onset, quality and duration of analgesia produced
by Lignocaine Hydrochloride 1:80000 Adrenaline
with Buprenorphine versus Lignocaine
Hydrochloride with 1:80000 Adrenaline in minor oral
surgical procedures e.g. cyst enucleation,
alveoloplasty, third molar surgery, incision and
drainage of abscess There is paucity of literature
regarding the use of combination of Buprenorphine
1Postgraduate Student, 2,5Reader, 3Professor, 4Professor and Head, 6Senior Lecturer, Dept. of Oral and Maxillofacial Surgery,
ITS CDSR, Muradnagar, Ghaziabad
Address for Correspondence:
Himanshu Thukral
Postgraduate Student, Dept. of Oral and Maxillofacial Surgery,
ITS-CDSR, Muradnagar, Ghaziabad
Email:[email protected]
Received: 18/02/2015 Accepted: 10/07/2015
P
Comparative analysis of post operative analgesic requirement in patient undergoing minor oral surgery using buprenorphine with lignocaine versus lignocaine - a double blind study _________Thukral H et al.
J Dent Specialities.2015;3(2):164-169 165
and 2% Lignocaine with 1:200000 Adrenaline in
minor oral surgical procedures. In our study we
compared onset, quality and duration of post
operative analgesia of Buprenorphine along with 2%
Lignocaine with 1:200000 Adrenaline versus 2%
Lignocaine with 1:200000 Adrenaline in minor oral
surgical procedures.6,7,8,9
MATERIALS AND METHOD
The protocol for the study was approved by the
ethical committee of the institutional review board
and written informed consent was obtained from
every patient. One hundred patients requiring minor
oral surgery were included in the study. The patients
were randomized by a third party and allocated to one
of the two study groups. This allowed the patients
and the operators to remain unaware of the group
allocations.
Method of Preparation of the Solution
1 ml of Buprenorphine Hydrochloride injection I.P
which contains an equivalent of 0.3 mg
Buprenorphine was withdrawn into a syringe and
injected into a 30 ml vial of 2 % Lignocaine with
Adrenaline 1:200000. Thus each ml of local
anesthetic contained 0.01 mg of Buprenorphine. This
solution was labelled and used for the study.
Study Design
Double blinding of the operator and patient was
achieved by appointing a custodian who was not be a
participant in this study in any way .The custodian
prepared and dispensed the solution to the operator
allocating the patient into two groups, A and B
randomly, He maintained a record of the patient
details and the solution dispensed in custodian record,
a copy of which is attached as Annexure 1.
One of the solutions had 2 % Lignocaine
Hydrochloride with 1:200000 Adrenaline Bitartrate
along with Buprinorphine 0.3mg and other had 2 %
Lignocaine Hydrochloride with 1:200000 Adrenaline
Bitartrate for intra oral nerve block to achieve local
anesthesia.
Table – 1: Different minor surgical performed in
patients of two groups
Solution A/
Group I
Solution B/
Group II
ORTHODONTIC
EXTRACTION
32 30
IMPACTION 6 16
EXTRACTION 8 10
ALVEOLOPLASTY 4 4
Table – 2: Number of different nerve blocks given
in two groups Solution A/
Group I
Solution B/
Group II INFRA ORBITAL 15 15
INFERIOR ALVEOLAR 18 17
NASO PALATINE 3 1
GREATER PALATINE 18 19
POSTERIOR SUPERIOR ALVEOLAR
6 6
LONG BUCCAL 3 8
Pain Assessment
After the surgical procedure, patients were given a
self analysis form to evaluate the degree of post-
surgical pain. They were instructed to note the
intensity of pain and the number of postoperative
analgesics consumed during the next 72 hours, at
intervals of 2, 4, 6, 12, 24, 36 and 48h, 72h. Patients
daily rating of discomfort was done on a 3-point,
Numeric Rating Scale; (NPRS scale).
Patients were instructed to document the number of
rescue medication consumed and the timing of first
analgesic intake during the study period.
3ml of solution was used for every nerve block given
in this study.
Data Analysis
Results were calculated using the mean value and
standard deviation for each of the parameters
considered and checked for statistical significance
using the following:-
1. Descriptive data presented as mean + SD
2. Continuous data are analyzed by paired /
unpaired ‘t’ tests
3. Chi-square test to assess the statistical
difference between the two groups.
4. Mann–Whitney U test.
5. Chi square test
6. Wilcoxan test
7. Inter mixed analysis
RESULTS The mean onset of subjective symptoms for Solution
A was 42.54 seconds and the mean onset of
subjective symptoms for Solution B was 47.79
seconds. On applying t-test the mean difference
(5.250) was not significant (p = 0.697) indicating that
the mean time of onset for subjective symptoms in
solution A and solution B are comparable.
The mean duration of anaesthesia for Solution A was
224.13 minutes, and the mean of duration of
anaesthesia for Solution B was 230.17 min. On
applying t-test the mean difference (6.041) is not
significant as p = 0.727 (p > 0.05) therefore duration
of anaesthesia in minutes of solution A and of
solution B have no significant difference.
____________________________________________________________________Original Research
J Dent Specialities.2015;3(2):164-169 166
Table - 3: Time at Which First Rescue Medication Taken (Duration of Analgesia)
SOLUTION A + SOLUTION B
GRAPH- 5 Showing Duration of Analgesia in Minutes in Solution A and Solution B
∆ Each Patient Reading in Solution A
▄ Each Patient Reading in Solution B
X Mean Reading in Solution B
◊ Mean Reading in Solution A
The mean of total number on analgesic tablets taken
for Solution A was 2.88 tablets and the mean of total
number on analgesic tablets taken for Solution B in
minutes was 1.29 tablets. On applying t-test the mean
difference (1.596) is significant as p = 0.022 (p <
0.05) indicating that there was a significant difference
in the requirement of postoperative pain control for
solution A as compared to solution B . The patient
who received solution A took more tablets for pain
control as compared to those who receive solution B
gives more post operative analgesia.
Three patients (6%) in Solution B out of 50 reported
of nausea, severe vomiting and dizziness and 3% out
of 100 patients reported of side effects.
DISCUSSION
In recent years, there has been an increase awareness
of the importance of effective pain management.
Although the currently available armamentarium of
analgesic drugs and techniques is impressive,
postoperative pain is not always effectively
treated.10,11,12,13 Routinely the patients undergoing
minor oral surgical procedures are prescribed some
form of NSAIDs to overcome the sequel of
postoperative pain.14,15,16
Pain may be described as an unpleasant sensory and
emotional experience associated with actual or
potential tissue damage.3,4,17 Pain itself is subject to
much inter individual variability with regard to
threshold and tolerance and has exceptional and
emotional components.18,19,20
Hence arises, the need for an agent which reduces
postoperative pain and additional intake of NSAIDs
which in turn shall help in negating the adverse
effects resulting due to excessive use of NSAIDs.21,22
0
10
20
30
40
50
60
70
80
0 10 20 30 40 50 60
Tim
e in
Ho
urs
Number Of Patients
hrs
hrs
hrs
hrs
Comparative analysis of post operative analgesic requirement in patient undergoing minor oral surgery using buprenorphine with lignocaine versus lignocaine - a double blind study _________Thukral H et al.
J Dent Specialities.2015;3(2):164-169 167
Over the past ten years several studies have suggested
that addition of certain opiates to the local anesthetic
used for block anesthesia may provide effective and
prolonged post-operative analgesia.23 The presence of
opioid receptors in peripheral nervous system offers
the possibility of providing postoperative analgesia in
ambulatory surgical patients.24,25
One of major problems in developing countries in the
speciality of anaesthesia is the availability of drugs.
Buprenorphine is not easily available in country
,pethidine13 and Morphine are other drugs ,the
availability of which can be problem as both these
drugs are subjected to Controlled Drugs Act with
only a certain quota released to hospital at variable
interval.26,27 Its low abuse potential, its cardiovascular
stability, longer duration of action, and its potential
safety in over dosage outweigh its disadvantages
especially in major surgery and in situations where
shorter acting drugs are not available.26,28,29
Buprenorphine is an FDA approved drug that is used
to treat opiate dependence and prevent its relapse. It
was first synthesized in 1966. Buprenorphine is a
semisynthetic, oripavine alkaloid derived from
Thebaine. It is long acting, lipid soluble, mixed
agonist antagonist opoid analgesic, which is at least
25 to 50 times more potent than Morphine.
Buprenorphine was one of the first narcotic
analgesics to be studied for its abuse liability in
humans22. Thus, an intramuscular injection of
Buprenorphine 0.3 mg is equipotent to morphine 10
mg, but the analgesia produced by Buprenorphine
lasts significantly longer. A ceiling effect for
respiratory depression but not for analgesia has been
demonstrated in humans.30,31
This prolonged duration appears to be because
buprenorphine seems to dissociate very slowly from
opioid receptors, so the usual duration of action is
about 8 hours after parenteral administration.32
Buprenorphine was initially classified as mixed
agonist–antagonist analgesia or as a narcotic
antagonist analgesic in most preclinical anti-
nociceptive tests; Buprenorphine was shown to be
fully efficacious, with an antinociceptive potency 20
to 70 times higher than that of Morphine.23,27
Viel et al in 1998 the investigators compared the
effect of Buprenorphine with that of morphine added
to 0.5% Bupivacaine on the duration of analgesia
after supraclavicular brachial plexus block.11 A study
by Romero et al indicated that the mean terminal
half-life of intravenously given Buprenorphine (1 mg
infused over 30 minutes) was about 6 hours.33
Kuhlman et al reported a mean terminal half-life of
3.2 hours after single doses of 1.2 mg given
intravenously.
Sittl et al in 2006 suggested that Buprenorphine has
an antinociceptive potency about 75 to 100 times
greater than that of morphine. Buprenorphine has a
dose-dependent effect on analgesia with no
respiratory depression. Dahan and colleagues in 2006
demonstrated that Buprenorphine has a ceiling effect
on respiratory depression, but not on analgesia. This
was demonstrated over a dose range of 0.05 to 0.6 mg
Buprenorphine in humans. Buprenorphine shows
analgesic effects, but no respiratory depression, at
doses up to 10 mg. Therefore, Buprenorphine may
have a differential effect on respiration and
analgesia.34 Bazin et al. studied the effect of addition
of morphine, buprenorphine and sulfetanil to local
anesthetic in brachial plexus block. The results
obtained showed that addition of morphine or
buprenorphine to local anesthetic produced
significant difference in duration of analgesia when
compared to the control group, wherein only local
anesthetic was used. Similar results were found in our
study, where Group I patients had significantly lesser
mean pain scores at varying time intervals
postoperatively (up to 33± 1.5 h) compared to Group
II patients. Mean pain scores obtained at 48 and 72 h
postoperatively did not vary significantly in Group I
compared to the Group.11,12
In the present study, a clinical prospective
randomised double blind study was conducted of 100
patients undergoing minor oral surgical procedures.
Each patient was anesthetized by using either
Solution A or B after taking informed consent and the
parameters decided as per the performance recorded.
Double blinding of the operator and patient was
achieved by appointing a custodian who was not be a
participant in this study in any way. The custodian
prepared and dispensed the solution to the operator
allocating the patient into two groups, A and B
randomly, He maintained a record of the patient
details and the solution dispensed in custodian record.
One of the solutions had 2 % Lignocaine
Hydrochloride with 1:200000 Adrenaline Bitartrate
along with Buprinorphine 0.3mg and other had 2 %
Lignocaine Hydrochloride with 1:200000 Adrenaline
Bitartrate for intra oral nerve block to achieve local
anesthesia22.
The mean ± standard deviation of onset of anesthesia
time in seconds of subjective symptoms are (42 ±
12.364 seconds) and (47.79 ± 14.479 seconds) in
Solution A and Solution B respectively.
On applying t-test the mean difference (5.250) is not
significant as p = 0.697 (p > 0.05) indicating that the
mean time of onset of anaesthesia in solution A and
solution B are comparable.
The mean ± standard deviation of onset of anesthesia
time in seconds of objective signs are (49.88 ± 9.786
seconds) and (53.83 ± 15.262 seconds) in Solution A
and Solution B respectively.
On applying t-test the mean difference (3.95) is not
significant as p = 0.709 (p > 0.05) indicating that the
mean time of onset of anaesthesia in solution A and
solution B are also comparable.
Comparative analysis of post operative analgesic requirement in patient undergoing minor oral surgery using buprenorphine with lignocaine versus lignocaine - a double blind study _________Thukral H et al.
J Dent Specialities.2015;3(2):164-169 168
The mean ± standard duration of surgery in minutes
are (8.17 ± 8.579 minutes) and (9.42 ± 8.382
minutes) performed under the effect of Solution A
and Solution B respectively.
On applying t-test the mean difference (1.25) is not
significant as p = 0.813 (p > 0.05) indicating that
duration of surgery performed under the effect of
both solutions, A and B was similar and statistically
not significant.
The mean ± standard duration of anesthesia in
minutes are (224.13 ± 22.142 minutes) and (230.17 ±
30.792 minutes) in Solution A and Solution B
respectively.
On applying t-test the mean difference (6.041) is not
significant as p = 0.727 (p > 0.05) so we can say that
duration of surgery in minutes of solution A and
solution B have no significant difference.
The mean ± standard of total number of analgesic
medication taken per day until follow up after 72
hours were (2.88 ± 1.424 tablets) and (1.29 ± 1.922
tablets) for Solution A and Solution B respectively.
On applying t-test the mean difference (1.596) is
significant as p = 0.022 (p < 0.05) indicating that
there was a significant difference in the requirement
of postoperative pain control for Solution A and
Solution B.
Three patients (6%) in Solution B out of 50 reported
of nausea, severe vomiting and dizziness and 3% out
of 100 patients reported of side effects.
The mean ± standard of post surgical analgesia was
(13.71 ± 7.95 hours) and (39.58 ± 1.922 hours) for
Solution A and Solution B respectively. On applying
t-test the mean difference (2.587) was significant as p
= 0.028 (p < 0.05) indicating duration of analgesia
differed significantly for Solution A and Solution B.
We concluded that addition of 0.3 mg of
Buprenorphine to 30 ml Lignocaine with Adrenaline
1:200000 for minor oral surgery results in significant
improvement in postoperative analgesia up to 39 h
and markedly reduces the need for excessive
analgesic intake. Thus reducing the adverse effects
associated with excessive use of NSAIDs. Further
studies needs to be done as there is less literature
about Buprenorphine added to local anaesthetist.
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How to cite this article: Thukral H, Singh S, Aggarwal A, Kumar
S, Mishra V, Anand KR. Comparative analysis of post operative
analgesic requirement in patient undergoing minor oral surgery using buprenorphine with lignocaine versus lignocaine - a double
blind study. J Dent Specialities, 2015;3(2):164-169.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
____________________________________________________________________Original Research
J Dent Specialities.2015;3(2):170-175 170
Assessment of collagen and elastic fibres in various stages of oral
submucous fibrosis using Masson's trichrome, Verhoeff vangieson and
picrosirius staining under light and polarizing microscopy
Nitu S S Mishra1, Sangeeta P Wanjari2, Rajkumar N Parwani3, Panjab V Wanjari4, Sumedha P Kaothalker5
ABSTRACT Background: Oral Submucous Fibrosis (OSMF) is a collagen related disorder seen in
habitual betel-quid chewers. This is a high risk precancerous condition which clinically
presents vertical palpable fibrous bands in buccal mucosa, generalized fibrosis of oral soft
tissues with restricted mouth opening. Present study was undertaken to ascertain the
changes occurring in collagen type I & III and elastic fibres in OSMF in relation to
orientation, density and thickness.
Study Methods: The study was performed on 15 cases in each group such as Stage I
OSMF, Stage II OSMF, Stage III OSMF and normal oral mucosa (NOM). The biopsied
samples were routinely processed for paraffin embedding; stained with Hematoxylin and
Eosin as well as special stains like Masson's Trichrome (MT), Verhoeff Van Gieson
(VVG) and Picrosirius red (PSR) and examined under light and polarized microscope
respectively. MT stain demonstrated all types of collagen fibers collectively while PSR
stain under polarized microscopy demonstrated collagen type I and type III separately
with enhanced birefringence. VVG stain demonstrated very fine black colored elastic
fibers, thus changes taken place could be accurately ascertained with progression of the
disease.
Results: Change in the orientation of collagen type I has been observed in stage II and
stage III of OSMF from haphazard to parallel in relation to surface epithelium, while no
change was noted in type III collagen fibres as well as elastic fibres in any stage of
OSMF, and remained haphazardly arranged. Increased density of type I collagen was
observed with increasing stage of OSMF from moderately dense to dense, while decrease
in density of type III collagen was noticed in stage III than in stage II OSMF from
moderately dense to sparse. The density of elastic fibres was decreasing from dense in
stage I to sparse in stage III. Thickness of collagen type I was increasing with increasing
grades while type III collagen and elastic fibres remained unchanged.
Conclusion: The alterations in orientation, density and thickness of collagen fibres and
density of elastic fibres in various grades of OSMF contribute to the clinical presentation
of trismus with progression of the disease.
Key Words: Collagen type I, Collagen type III, Elastic fibres, Masson's trichrome stain,
Verhoeff Van Gieson stain, Picrosirius red stain
INTRODUCTION
ral submucus fibrosis (OSMF) is a chronic
debilitating disease of oral mucosa characterized
by generalized fibrosis of the oral soft tissues which
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DOI: 10.5958/2393-9834.2015.00009.1
tend to present itself clinically as palpable fibrous
bands.1 The most common initial symptoms of
OSMF are burning sensation of oral mucosa
aggravated by spicy food, followed by either
hypersalivation or dryness of the mouth.2 It may also
be preceded by ulceration or pain.1 The hallmark of
OSMF is that it affects most parts of oral cavity,
pharynx and upper third of esophagus leading to
dysphagia and progressive trismus due to rigid lips
and cheeks.3
The overall prevalence rate of OSMF in India is
about 0.2% to 0.5% and prevalence by gender
varying from 0.2 to 2.3% in males & 1.2 to 4.57% in
1Senior Lecturer, 2Professor & Head, 3Professor, 4Professor & Dean,
Department of Oral Pathology &
Microbiology, Modern Dental College & Research centre, Indore (M.P.)
5Consultant, Oral Pathologist, Insight
Diagnostics, 46, Varruchi Marg, In front of Madhav Nagar Police Station,
Freegunj, Ujjain (M.P.)
Address for Correspondence:
Dr. Sangeeta Wanjari, Professor & Head
Department of Oral Pathology &
Microbiology, Modern Dental College & Research Centre, Indore (M.P.)
Email: [email protected]
Received: 24-10-2014 Accepted: 26-03-2015
O
Assessment of collagen and elastic fibres in various stages of oral submucous fibrosis using masson's trichrome, Verhoeff vangieson and picrosirius staining under light and polarizing microscopy __________________________________________________________________Mishra NSS et al.
J Dent Specialities.2015;3(2):170-175 171
females. The age range of the patients with OSMF is
wide which ranges between 20 to 40 years.4
The disease is most commonly found in youth as they
are more attracted to commercially available areca
nut products.5 The alkaloids and flavonoids from
arecanut stimulate proliferation of fibroblasts and
collagen synthesis.6 OSMF fibroblasts synthesize
large amount of collagen compared to normal
fibroblasts.7 Thus in OSMF connective tissue
changes are characterized by deposition of dense
collagen fibers.1 Moreover hyaline degeneration,
fragmentation and elastic degeneration are
characteristic observations with the progress of the
disease.8
About 26 types of collagen fibers are identified so far
depending on molecular structure. Of these collagen;
type I is most abundant interspersed by type III in
connective tissue.9 Routine Hematoxylene and Eosin
(H&E) and Masson's Trichrome stain (MT)
demonstrate all types of collagen collectively.
However Picrosirius red (PSR) stain under polarized
microscopy demonstrate collagen type I and type III
separately with enhanced birefringence. Collagen
type I appear as closely packed thick fibers with
intense birefringence of yellow / orange to red color
and correspond to collagen fibers. However collagen
type III appear as loosely packed thin fibrils which
display a weak birefringence of green to greenish-
yellow color that could be identified as reticular
fibers. Thus characterization of collagen becomes
specific and reliable with variable thickness and
different color intensities of birefringence.10, 11
Normal mucosa is elastic, flexible and resilient.
Elastic fibers are the major insoluble extracellular
matrix assemblies that endow resilience to connective
tissue permitting long range deformability.12
However in OSMF oral mucosa shows reduced
elasticity and flexibility with progress of disease
because of deposition of excessive collagen.
Thus the purpose of this study was to ascertain the
importance of orientation, density and thickness of
collagen type I and type III and elastic fibers in
various stages of OSMF.
MATERIALS AND METHODS
The present study included 15 NOM and 45 OSMF
subjects which were divided equally in three groups
as stage I, II and III following clinico-functional
classification by Haider et al (2000) after obtaining
written consent of the patient and institutional ethical
committee clearance.
Further incisional biopsy was performed from buccal
mucosa for the selected cases, fixed in 10% neutral
buffered formalin and processed for paraffin
embedding. 4 µm thick sections were obtained using
semiautomatic microtome, stained with MT, VVG
and PSR stains based on standard protocol, and
observed under light and Polarized microscope
respectively.13 Thickness of collagen and elastic
fibers was measured with the help of LYNX software
(Lawrence & Mayo) in 10 randomly selected fields
per sample without overlapping.
RESULTS
Present study revealed following results -
Orientation of collagen and elastic fibres:
The collagen fibres (MT stained) [Fig-1] and type I
collagen (PSR stained) exhibited haphazard
arrangement in NOM and stage I OSMF, while its
orientation was changed and appeared parallel to the
surface epithelium in stage II and III OSMF.
However type III collagen (PSR stained) and Elastic
fibers (VVG stained) did not show any alteration in
various stages of OSMF from NOM and appeared
haphazard (Table-1) [Figure-2]
Table-1: Pattern of Orientation of Collagen & Elastic fibers in relation to
the surface epithelium in NOM and OSMF
NOM (15) STAGE I (15) STAGE II (15) STAGE III (15)
COLLAGEN IN MT Haphazard Haphazard Parallel Parallel
COLLAGEN TYPE I IN PSR Haphazard Haphazard Parallel Parallel
COLLAGEN TYPE III IN PSR Haphazard Haphazard Haphazard Haphazard
ELASTIC FIBERS IN VVG Haphazard Haphazard Haphazard Haphazard
Assessment of collagen and elastic fibres in various stages of oral submucous fibrosis using masson's trichrome, Verhoeff vangieson and picrosirius staining under light and polarizing microscopy __________________________________________________________________Mishra NSS et al.
J Dent Specialities.2015;3(2):170-175 172
Density of collagen and elastic fibres: Type I collagen fibers (PSR stained) appeared moderately dense in NOM and stage I OSMF, while its density
increased in stage II & stage III OSMF. [Figure-2]
Similarly density of Type III collagen fibers (PSR stained) appeared moderate in NOM, stage I & stage II OSMF but
it was sparse in stage III OSMF. [Figure-2]
Moreover dense elastic fibers (VVG stained) were observed in NOM and stage I OSMF, which showed decrease in
density with progress of OSMF and appeared moderately dense in stage II OSMF and sparse in stage III OSMF.
(Table 2) [Figure-3]
Table-2: Comparison of density of Collagen & Elastic fibers in NOM and OSMF
DENSITY OF FIBERS NORMAL
(15) STAGE I
(15) STAGE II
(15) STAGE III
(15)
COLLAGEN TYPE I IN
PSR MOD DENSE MOD DENSE DENSE DENSE
COLLAGEN TYPE III IN
PSR MOD DENSE MOD DENSE MOD DENSE SPARSE
ELASTIC FIBERS IN VVG DENSE DENSE MOD DENSE SPARSE
Thickness of collagen and elastic fibres:
Measured thickness of collagen fibres (MT stain) [Fig-1] and type I collagen (PSR stained) was more in OSMF than
NOM. [Fig-2] Moreover progressive increase in thickness was noticed with advancement of OSMF.
Type 3 collagen fibres [Fig-2] and Elastic fibres [Fig-3] showed little variation in thickness in NOM and various
stages of OSMF. (Table 3)
Table-3: Comparison of thickness of Collagen fibres, Collagen type I,
Collagen III & Elastic fibers in NOM and OSMF in µm
THICKNESS OF FIBERS NORMAL
(15) STAGE I
(15) STAGE II
(15) STAGE III
(15)
COLLAGEN FIBRES IN MT 1.1 2.5 3.9 8.7
COLLAGEN TYPE I IN
PSR 1.9 4.1 7.1 11.7
COLLAGEN TYPE III IN PSR 1.8 1.9 2.0 1.68
ELASTIC FIBERS IN VVG 1.2 1.2 1.1 1.2
Figure-1: Photomicrograph Showing Orientation of Collagen Fibers In Relation To the Surface Epithelium in
Various Stages of OSMF (MT)
Stage I Stage II Stage III
Assessment of collagen and elastic fibres in various stages of oral submucous fibrosis using masson's trichrome, Verhoeff vangieson and picrosirius staining under light and polarizing microscopy __________________________________________________________________Mishra NSS et al.
J Dent Specialities.2015;3(2):170-175 173
Figure-2: Photomicrograph Showing Orientation of Collagen Type I & Type III Fibers In Relation To the
Surface Epithelium in Various Stages of OSMF (PSR)
Stage I Stage II Stage III
Figure-3: Photomicrograph Showing Orientation of Elastic Fibers In Relation To the Surface Epithelium in
Various Stages of OSMF (VVG)
Stage I Stage II Stage III
DISCUSSION
OSMF is a chronic disease and a well-recognized
potentially malignant condition of the oral cavity
characterized by inflammation and a progressive
fibrosis of the lamina propria and deeper connective
tissue. Various authors have agreed that pathological
alteration in OSMF begin in the lamina propria and
the epithelium responds only secondarily. Fibrosis
and hyalinization extends into muscle bundle zone
resulting into atrophy of the muscles. MT is a special
stain which offers a simultaneous contrast color to
the collagen fibers along with muscle fibers
facilitating better visual discrimination between
them.8
Collagen is the major structural element of the
connective tissue which contributes to the stability
and maintains structural integrity. It contributes to the
entrapment, local storage and delivery of growth
factors and cytokines and play an important role
during organ development and tissue repair. So far 26
genetically distinct collagen types have been
described. Type I collagen fibers form the bulk of
subepithelial collagen while type III is intermixed
with it.9 PSR is the special stain for connective tissue
especially for differentiating collagen subtypes.11 It
works on the principle that sulfonic group of sirius
red- a strong cationic dye reacts with the basic groups
present in collagen molecules. The elongated dye
molecules are attached to collagen fibers in such a
way that their long axis is parallel. This parallel
relationship between dye and collagen molecules
results in enhanced birefringence. The role of picric
acid is to prevent the indiscriminate staining of non
collagenous structures by sirius red.2
Enhanced birefringence of the fibers could be
demonstrated by polarizing microscopy. Various
colors exhibited by different types of collagen
provide information regarding the type of the
collagen with respect to its physical aggregation and
morphological appearance. Thus these polarizing
colors help in grading the severity of the disease.
Assessment of collagen and elastic fibres in various stages of oral submucous fibrosis using masson's trichrome, Verhoeff vangieson and picrosirius staining under light and polarizing microscopy __________________________________________________________________Mishra NSS et al.
J Dent Specialities.2015;3(2):170-175 174
Moreover it may serve as an excellent adjunct to
electron microscopic study.10
Present study revealed haphazard orientation of
collagen fibres as well as type I collagen in NOM and
stage I OSMF, while in stage II and stage III most of
them were arranged parallel to the surface
epithelium. Type III collagen fibers showed
haphazard orientation in NOM and all stages of
OSMF. Contrasting to these findings Parveen S et al
(2013) observed parallel orientation of thin (type III)
and thick (type I) collagen fibers to the epithelium in
all grades of OSMF and stated that the cause for
these unidirectional or parallel alignments may be
due to -
• Chronic stimulation of oral mucosa by
irritation or as sequence of mechanical stress.
• Due to force generated by cell mediated gel
contraction.
• Due to changes in the extracellular matrix
imbalance production and degradation.1
Moreover Smitha BR et al (2013) explained that
parallel orientation of collagen fibers to the
epithelium in 68% in buccal mucosa and 78% in
labial mucosa of OSMF subjects was due to their
deposition in the direction of opening and closing
movement of mouth.2
Density of collagen type I and type III appeared
moderate in NOM as well as in stage I OSMF,
however collagen type I appeared denser in stage II
and stage III OSMF. Collagen type III appeared
moderately dense in NOM and stage I and stage II
OSMF, while they were sparse in type III OSMF.
These findings show increased density of collagen
type I with increasing stages of OSMF and was found
to be statistically significant ( p<0.05), while density
of type III collagen appeared same in NOM and
stage I & II OSMF, and reduced in type III OSMF.
These findings are consistent with Parveen S et al
(2013), Kamath VV et al (2013), Ganganna K et al
(2012) and Ceena DE et al (2009).1,11,14,15 Kamath
VV et al has further explained the reduction in type
III fibres to be on the basis of the compaction
(removal of extracellular matrix substance) during
progressive maturation of the fibres.11
In the present study average thickness of collagen
fibers in stage I, III and III OSMF was 2.52 µm ±
0.19; 3.96 µm ± 0.50 and 8.7 µm ± 1.5 respectively
while 1.11 µm ± 0.43 in NOM. Further assessment of
average thickness of type I collagen under polarizing
microscope revealed 4.15 µm ± 0.86; 7.18 µm ± 0.83
and 11.7 µm ± 1.0 in stage I, II and III respectively
and 1.90 µm ± 0.72 in NOM. This demonstrates that
there is great increase in thickness of type I collagen
with increasing stages of OSMF and further it can be
stated that polarized microscopy after PSR staining
gives more precise measurement due to different
pattern of birefringence. Ganganna K et al (2012),
Ceena DE et al (2009) and Kamath VV et al (2013)
too observed increase in thickness of collagen fibres
with increasing grades of OSMF.11,14, 15 Moreover in
the present study average thickness of type III
collagen in NOM, stage I and II OSMF appeared
nearly same with slight reduction in stage III OSMF.
However Kamath VV et al (2013) observed variable
results for type III collagen.11
The normal lining mucosa shows elastic fibers
interlacing in all directions and provide elasticity. A
VVG special stain demonstrates very fine black
colored elastic fibers. The changes taken place in
elastic fibers thus could be accurately ascertained by
VVG staining.13
The present study demonstrated haphazard
orientation of elastic fibers in all directions in NOM
and all stages of OSMF which was statistically
significant (Kruskal- Wallis Test).
Moreover the density of elastic fibres in NOM and
stage I OSMF appeared more, which was moderate in
stage II and sparse in stage III OSMF. These findings
demonstrated that density of elastic fibers decreases
with progress of disease and results were statistically
significant (p<0.05).
However observed average thickness of elastic fibers
in stage I, II and III OSMF was 1.20 µm ± 0.08, 1.19
µm ± 0.07 and 1.2 µm ± 0.08 respectively while in
NOM it was 1.2 µm ± 0.08; which suggests that there
is no much change in thickness of elastic fibres in
OSMF when compared to NOM.
From these observations an assumption can be made
that though thickness and orientation of elastic fibres
remain almost same in all stages of OSMF as NOM
the decreased density of elastic fibers could be
playing significant role in reduction of elasticity of
mucosa leading to decreased mouth opening.
CONCLUSION
It can be inferred that collagen fibers and elastic
fibers show minimal alternation in early stages. Once
the disease progress from early stages and patients
continues with arecanut chewing habit the fibrotic
changes in connective tissue accelerates in severity.
Unfortunately even after cessation of the causative
habit, all the clinical and histologic features of the
disease persists. Moreover collagen fibers change
Assessment of collagen and elastic fibres in various stages of oral submucous fibrosis using masson's trichrome, Verhoeff vangieson and picrosirius staining under light and polarizing microscopy __________________________________________________________________Mishra NSS et al.
J Dent Specialities.2015;3(2):170-175 175
their orientation and become unidirectional and
arranged parallel to the epithelium which can be
correlated with the direction of force.
Further polarized microscopic study strongly
suggests that type I fibers represented predominantly
as orange red- red colored fibrils and are deposited in
excess as severity of disease increases whereas type
III collagen fibers appear fine and show week
greenish yellow birefringence.14 These fibers
decrease with increase in severity which can be
explained as removal of extracellular matrix
substance during progressive maturation of fibers.1
However elastic fibers reduce with increase of
severity of disease. This can be correlated further
with decrease or loss of elasticity of mucosa with
progression of disease.
BIBLIOGRAPHY 1. Parveen S, Syed AA, Tanveer S. A Study on
Orientation of Collagen Fibers in Oral Submucous
Fibrosis. Int J Sci Res Pub. 2013;3:1-4.
2. Smitha BR, Donoghue M. Clinical and
histopathological evaluation of collagen fiber
orientation in patients with oral submucus fibrosis. J
Oral Maxillofac Pathol. 2011;15:154-60.
3. Gupta MK, Mhaske SA, Ragavendra R, Imtiyaz. Oral
submucous fibrosis - Current Concepts in
etiopathogenesis. People’s J Sci Res. 2008;1:39-44.
4. Gannepalli A, Pancha VB, Ayinampudi BK, Putcha
UK, Tom A. Quantitative and qualitative analysis of
collagen in oral submucous fibrosis. J. Dr NTR UNIV
Health Sci. 2012;1:99-105.
5. Ali FM, Aher V, Prasant MC, Bhushan P, Mudhol A,
Suryavanshi H. Oral submucous fibrosis: Comparing
clinical grading with duration and frequency of habit
among areca nut and its products chewers. J Can Res
Ther. 2013;9:471-76.
6. Reddy VN, Wanjari PV, Banda NR, Reddy P. Oral
submucous fibrosis: correlation of clinical grading to
various habit factors. Int J Dent Clin. 2011;3:21-24.
7. Sudarshan R, Vijaybala G, Raj KSD. Diagnostic
Approaches for Oral Submucous Fibrosis. Universal J
Pharm. 2013;2:37-41.
8. Savita JK, Girish HC, Murgod S, Kumar H. Oral
submucous fibrosis- A review (Part 2). J Health Sci
Res. 2011;2:38-46.
9. Gelse K, Poschl E, Aigner T. Collagens—structure,
function, and biosynthesis. Adv Drug Deliv Rev.
2003;55:1531-46.
10. Junqueira LCU, Montes GS, Sanchez EM. The
influence of tissue section thickness on the study of
collagen by picrosirius polarization method. J
Histochemistry. 1982;74:153-56.
11. Kamath VV, Satelur K, Komali Y, Krishnamurthy SS.
Image analysis of collagen types and thickness in oral
submucous fibrosis stained with picrosirius red under
polarizing microscope. J Orofac Sci. 2013;5:123-27.
12. Kielty CM, Sherratt MJ, Shuttleworth CA. Elastic
fibres. J cell sci. 2002;115:2817-28.
13. Bancroft JD, Gamble M. Theory and practise of
histological technique. 6th ed. Philadelphia. Elseviers
publication. 2008:150-52.
14. Ganganna K, Shetty P, Shroff SE. Collagen in
Histologic stages of Oral submucous Fibrosis: A
Polarizing Microscopic study. J Oral Maxillofacial
Pathol 2012;16:162-66
15. Ceena DE, Bastian TS, Ashok L, Annigeri RG.
Comparative study of clinicofunctional staging of Oral
Submucous Fibrosis with qualitative analysis of
collagen fibres under polarizing microscopy. Indian J
Dent Res. 2009;20:271-76.
How to cite this article: Mishra NSS, Wanjari SP, Parwani RN, Wanjari PV, Kaothalker SP. Assessment of collagen and elastic
fibres in various stages of oral submucous fibrosis using Masson's
trichrome, Verhoeff vangieson and picrosirius staining under light and polarizing microscopy. J Dent Specialities 2015;3(2):170-172.
Source of Support: NIL
Conflict of Interest: NIL
_______________________________________________________________________________Invited Review
J Dent Specialities.2015;3(2):176-179 176
Bacterial colonization at implant – abutment interface: a
systematic review Tabrez Lakha1, Mohit Kheur2, Supriya Kheur3, Ramandeep Sandhu4
ABSTRACT Background: Although implants have shown to have a high success rate, clinicians are
also called upon to encounter numerous complications and failures. Among the numerous
reasons of failures, peri-implantitis is reported to account for 10% of the failures. As the
oral cavity provides a natural habitat for various micro-organism due to its non-shedding
surface, there is some evidence that gram-negative anaerobic rods colonize around the
implant leading to peri-implanitis. This colonization is dependent on various factors such
as the micro-gap at the implant- abutment interface, the precision of fit, degree of micro-
movement and applied torque.
Aim and Objective: The aim of this article is to provide an overview of current literature
on bacterial colonization on the implant surface and the influence of different implant-
abutment designs on bacterial colonization.
Material and Methods: An electronic search was conducted using the PubMed
(Medline), PubMed central and Google scholar to identify articles published on bacterial
colonization at the implant-abutment interface. The following search words were used:
microbioleakage at implant-abutment interface, surface characteristics/roughness of
implants, bacterial adhesion on dental implants, bacterial colonization at implant
abutment surface. The articles included in the review comprises of in vitro studies, in vivo
studies, review abstracts and review articles.
Results: The total number of articles for the key words” microbioleakage at implant-
abutment interface” were 29 and for the key words” bacterial colonization at implant
abutment interface“ were 17. After considering the inclusive and exclusive criteria, case
report, case series and review articles were excluded. 11 articles were considered eligible
based on their relevance to the subject.
Conclusion: Although micro-gap formation inevitably occurs at the implant-abutment
interface. The current literature highlights that the formation of this micro-gap is
influenced by the type of implant-abutment design used. Though the results are
insignificant, recent in vivo and in vitro studies have proved that external hexagon results
in higher micro leakage compared to other connections used .Morse-taper connections
shows the least amount of microbial leakage.
Key words: Implant-abutment interface, Microbial leakage, Bacterial colonization
INTRODUCTION
mplant failures can be divided into early and late
failures.1,2 Early failures are described as failures
which have occurred before the abutment connection
and are generally caused by inadequate
osseointegration. Studies have shown correlation
between age, gender, insertion site, fixture length,
smoking and success of an implant.3-4 Late failures
occur after occlusal loading of the implant and has
been associated with plaque induced peri-implantitis.
Since two- stage implant system are frequently used
they result in a micro-gap at the implant-abutment
junction, this hollow space provides a favourable site
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DOI: 10.5958/2393-9834.2015.00010.8
for bacterial colonization and leads to inflammatory
process at implant-abutment interface.5-6 This
infiltration of bacteria is a major contributory factor
leading to perimplantitis.1
Peri-implantitis is a progressive disease of implant
involving hard and soft tissues resulting in bone
resorption, decreased osseointegration, pocket
formation and purulence. Bone resorption may be
induced by bio mechanical stress, bacteria, or a
combination of both. However bacteria may be the
primary factor, anaerobic bacteria have been
observed growing in the micro-gap present at the
implant-abutment interface and in the peri-implant
sulcus.7The infiltration of the bacteria at implant
abutment interface has been shown to depend on the
type of implant-abutment connection and their
sealing capacity.8
The frequently used abutments in different implant
systems are internal hexagon, external hexagon,
cylinder hex, conical, octagonal, spline cam, cam
tube, pin/slot.9 The hexagon design is oldest and was
the most commonly used design, however it had
1,4Post Graduate Student, 2Professor, Department of Prosthodontics,
M.A.Rangoonwala College of Dental
Sciences and Research Centre, Pune, India. 3Professor and Head of the Department
of Oral Pathology and Microbiology of D.Y.Patil Dental College, Pimpri,
Pune, India
Address for Correspondence:
Dr. Tabrez Lakha Post Graduate Student, Department of
Prosthodontics, M. A. Rangoonwala
College of Dental Sciences and Research Centre, Azam Campus,
Hidayatullah Road, Pune 411011.
E-mail: [email protected]
Received: 18/01/2015
Accepted: 08/06/2015
I
Bacterial colonization at implant – abutment interface: a systematic review ____________________Lakha T et al.
J Dent Specialities.2015;3(2):176-179 177
shortcomings like screw loosening and compromised
rotational and lateral stability.9 Therefore to
overcome the shortcomings different designs of
abutments were developed, out of the designs
mentioned conical abutments have gained popularity
as it provides mechanically sound, stable self-locking
interface.10,11 Since it provides a friction lock, it
minimizes the micro-gap present at implant-abutment
interface. It has been suggested that conical
connection reduces bacterial infiltration at implant
abutment interface.12
MATERIAL AND METHODS
An electronic Search was conducted using the
PubMed (Medline), PubMed central and Google
scholar to identify articles published on bacterial
colonization at the implant-abutment interface. The
following search words were used: microbioleakage
at implant-abutment interface, surface characteristics/
roughness of implants, bacterial adhesion on dental
implants, bacterial adhesion on implant abutment
surface. Literature covering both in vivo, in vitro
studies and review articles were included.
RESULTS
The total number of articles for the key words”
microbioleakage at implant-abutment interface” were
29 and for the key words “bacterial colonization at
implant abutment interface” were 17.
After considering the inclusive and exclusive criteria
case report, case series and review articles were
excluded. 11 articles were considered eligible based
on their relevance to the subject.
The articles were categorized with respect to the
current literature on microbial leakage at implant-
abutment interface, influence of torque values,
roughness, and type of abutment connections which
influences the microbial colonization at the interface.
To highlight the important aspects and to give a clear
overview of the literature, the articles have been
described in various headings.
ABUTMENT DESIGNS
Implant-abutment connections can be categorized
into internal and external connection. The distinctive
feature which separates the two is the presence and
absence of geometric feature extending on the
coronal surface of the implant.
This can be categorized as a slip-fit joint where a
space exist between the implant – abutment interface
or a frictional fit where there is minimal space at the
interface. This geometry can be of following types
octagonal, hexagonal, cone screw, cone hex, cylinder
hex, sline cam, cam tube and pin / slot.9
There has been various in vivo and in vitro studies
which have evaluated the micro-gap present at the
interface of the different designs and the microbial
leakage at the interface.
IMPLANT-ABUTMENT INTERFACE-THE
MICROBIAL LINK
Two piece implant system consists of the endosteal
part (implant) which is placed during the first surgical
phase and the mucosal part (abutment) which is
attached after osseointegration. Screwing the
abutment to the implant results in gap between the
two components. It has been reported that this micro-
gap measures around 40-60μm, due to this gap there
is micro-movement during function which in turn
enhances microbial leakage.13 Presence of gap near
the alveolar crest is also responsible for 1mm of bone
loss during the first year of functional loading.14
The colonization of the bacteria at the implant-
abutment interface depends on factors like the
precision at the implant-abutment interface of
different implant system and their marginal fit, the
closing torque values also alters the sealing ability of
the abutments.15
To demonstrate the microbial leakage at implant-
abutment interface an in vitro study was carried out
on implant-abutment assemblies using blood serum
media inoculated with micro-organism. The serum
was incubated in anaerobic condition for 7 days with
the implants partially and completely immersed in it.
The micro-organisms from the implants were
collected and incubated in blood agar plates in
anaerobic conditions. The result of this study showed
presence of micro-organisms in both the assemblies
indicating bacterial leakage.16
Bacterial leakage have also been observed after
functional loading of implants, it has been shown that
chewing reduces component stability which favours
bacterial colonization at the micro-gap. When the
implants are subjected to functional loads there is
exchange of fluids between internal and external
environment which increases the bacterial infiltration
at the peri-implant area.
Therefore implant-abutment interface plays a vital
role in bacterial colonization, different connections
have been compared to evaluate their stability under
loading conditions.
Comparison between internal and external abutment
connections of different implants systems have
demonstrated that internal connections provide better
marginal fit at the interface, thus minimizing the
microbial leakage.
In vivo and in vitro studies have demonstrated that
among various connections used, Morse taper
connections achieved higher seal as it has frictional
lock system and thus reduced the bacterial infiltration
at the implant-abutment interface. Also conical
abutments showed superiority in terms of torque
maintenance and abutment stability which in turn
minimized the bacterial colonization.17 Though
external hexagon are one of the oldest and commonly
used abutment connections, they are considered to be
Bacterial colonization at implant – abutment interface: a systematic review ____________________Lakha T et al.
J Dent Specialities.2015;3(2):176-179 178
ineffiecient in preventing microbial leakage at the
implant-abutment interface.
An in vivo study was done on bacterial colonization
at the peri-implant sulcus and inside the implant
connection after 5 years of functional loading,
significant difference between connection type and
total bacterial counts was noted. Connections types
compared in the study were external hexagon,
internal hexagon with external collar and conical.
Bacteria belonging to the red and orange complex
were evaluated, these included Aggregatibacter
actinomy-cetemcomitans (Aa), Porphyromonas
gingivalis (Pg), Tannerella forsythensis (Tf),
Treponema denticola(Td), Prevotella intermedia (Pi),
Peptostreptococcus micros (Pm), Fusobacterium
nucleatum (Fn), Campylobacter rectus (Cr), Eikenella
corrodens (Ec), and Candida albicans (Ca).
Significant results were observed as the conical
connection showed least amount of red complex
bacteria as compared to external hexagon, and
internal hexagon with external collar.17
An in vitro study was also performed to evaluate the
bacterial leakage at the implant-abutment interface
and the sealing efficiency of implants when they were
subjected to in different torque values. The torque
values used was 20N.cm and 30N.cm. Higher
contamination was observed with implants in which
20N.cm torque was applied.15
DISCUSSION
Microbial penetration through the micro-gap
invariably exists at the implant-abutment interface.
This gap has shown to be a potential source of
microbial infiltration and peri-implantitis leading to
implant failure, as it offers a welcoming environment
for the bacteria to colonize.
Though conical connections have shown a better
sealing ability, micro-gap invariably exists at the
interface, therefore it can be stated that no connection
has completely eliminated the micro-gap formation or
has led to a sterile environment inside the implant
connection.
Type of connection used is one of the important
factor influencing bacterial adhesion, however other
factors should also be given prime importance when
implants are used. Factors such as surface roughness
of implants, the amount of torque used, the variability
or the changing oral micro flora has to be considered.
As it been shown that rapid biofilm formation occurs
at the implant surface which is difficult to clean.
There is a need to optimize the implant-abutment
connections in order to achieve better outcomes.
CONCLUSION
After analysing the current literature, it could be
concluded that bacterial colonization depends on
multiple factors and certain modifications should be
always undertaken to minimize the factors which
promote bacterial infiltration at the implant-abutment
interface. Current implant systems cannot safely
prevent microbial leakage and bacterial colonization
of the inner part of the implant. There is a need for
modifications to seal the implant-abutment contact
area.
Use of conical implants can be promoted as it has
better sealing abilities compared to other systems.
Manufacturers and clinicians must be aware of the
problem of microbial leakage, since it is likely that
microbial colonization of the marginal gap and the
inner part of the implant can result in soft tissue
inflammation leading to implant failure.
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contamination and marginal fit of the implant-
abuttment interface. Int J Oral Maxillofac Implants
1997;12:527-40.
13. do Nascimento C, Miani PK, Pedrazzi V, Gonçalves
RB, Ribeiro RF, Faria AC, Macedo AP, de
Albuquerque RF Jr. Leakage of saliva through
the implant-abutment interface: invitro evaluation of
three different implant connections under unloaded and
Bacterial colonization at implant – abutment interface: a systematic review ____________________Lakha T et al.
J Dent Specialities.2015;3(2):176-179 179
loaded conditions Int J Oral Maxillofac Implants.
2012;27:551-60.
14. Zipprich H, Weigl P, Lauer HC, Lange B. Micro-
movements at the implant-abutment interface:
measurements, causes and consequences.
Implantologie 2007;15:31-45.
15. Alves DC, Carvalho PS, Martinez EF. In vitro
microbiological analysis of bacterial seal at the
implant-abutment interface using two Morse taper
implant models. Braz Dent J. 2014;25:48-53.
16. Piattelli A, Scarano A, Paolantonio M, Assenza B,
Leghissa GC, Di Bonaventura G, Catamo G,
Piccolomini R. Fluids and microbial penetration in the
internal part of cement-retained versus screw retained
implant abutment connections. J
Periodontol. 2001;72:1146–50.
17. Canullo L, Penarrocha Oltra D, Soldini C, Mazzocco
F, Penarrocha, Covani U. Microbial assesement of the
implant-abutment interface in different
connections:cross-sectioal study after 5 years of
functional loading. Clin Oral Implants Res.
2015;26:426-34.
How to cite this article: Lakha T, Kheur M, Kheur S, Sandhu R.
Bacterial colonization at implant – abutment interface: a systematic
review. J Dent Specialities, 2015;3(2):176-179.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
_________________________________________________________________________Case Report
J Dent Specialities.2015;3(2):180-182 180
Revascularization of a necrotic, infected, immature permanent molar
with apical periodontitis: a case report Pallavi Vashisth1, Vatsala V2, Sathyajith Naik3, Mousumi Goswami Singh4
ABSTRACT The traditional techniques of chemo-mechanical instrumentation and disinfection of the
root canal system used in mature teeth are limited by the immature tooth’s anatomy. The
open apex is difficult or impossible to seal with conventional root filling methods because
of the absence of an apical stop. Furthermore, the arrested development of the dentinal
walls at the time of pulp necrosis leaves a weak tooth with thin dentinal walls that are
susceptible to fracture. The purpose of the paper is to present the case of a patient wherein
revascularization of the necrotic infected pulp space of an immature permanent
mandibular molar was induced by stimulation of a blood clot from the periapical tissues
into the canal space. The treatment approach can help rescue infected immature teeth by
physiologically strengthening the root walls.
Key words: Pulp revascularization, Immature apex, Apexification.
INTRODUCTION
ulpal necrosis of an immature permanent tooth
poses many potential complications. Rapidly
progressing dentinal caries or traumatic injuries in the
permanent teeth of young patients lead to pulp
inflammation and / or necrosis and apical
periodontitis, which subsequently interrupt the
development of the incompletely formed roots. The
presence of an open apex and thin fragile dentinal
walls presents a problem that complicates the clinical
management of pulp and periapical disease.1
The traditional techniques of chemo-mechanical
instrumentation and disinfection of the root canal
system used in mature teeth are limited by the
immature tooth’s anatomy.2 The mechanical cleaning
and shaping of a tooth with blunderbuss canal are
difficult, if not impossible. The thin, fragile lateral
dentinal walls can fracture during mechanical filing
and the large volume of necrotic debris contained in a
wide root canal is difficult to completely disinfect.
Many blunderbuss canals with flaring walls cannot be
obturated and sealed by orthograde methods and
might require apical surgery and retrograde sealing of
the canal.3
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DOI: 10.5958/2393-9834.2015.00011.X
Many techniques have been suggested for induction
of apical closure in pulpless teeth to produce more
favorable conditions for conventional root canal
filling. These techniques include surgery and
retrograde sealing, calcium hydroxide - induced
apical closure and placement of apical plug of
mineral trioxide and gutta percha obturation but
because of the thin dentinal walls, there is a high
incidence of root fractures in teeth after apexification.
Thus the concept of revascularization was introduced
by Ostby in 1961. Nygaard- Ostby hypothesized that
laceration of the periapical tissues until bleeding
occurred might produce new vital vascularized tissue
in the canal. He suggested that this treatment ‘may
result in further development of the apex’.4 In 1966
Rule and Winter documented root development and
apical barrier formation in cases of pulpal necrosis in
children.5 Since then there has been an ongoing
research in this field. This case report add another
example to dental literature supporting this treatment
modality as a successful alternative to conventional
procedure undertaken to treat necrotic, infected and
immature permanent teeth.
CASE REPORT
A 8 year old female patient reported to the
department with complaint of pain in mandibular left
posterior tooth. Clinical evaluation revealed carious
36. Radiograph interpretation showed carious lesion
approaching the pulp with open apices.(Fig 1) The
tooth did not respond to cold testing with CO2 ice,
heat test, the tooth was tender on vertical percussion.
The tooth was diagnosed with necrotic pulp. Access
was obtained to the pulp space, where a necrotic pulp
was confirmed clinically. The canal was instrumented
1Reader, 2Senior lecturer, 3Professor and Head,
Dept. of Pedodontics, Institute of
Dental Sciences, Bareilly 4Professor, Dept of Pedodontics, ITS
Greater NOIDA
Address for Correspondence:
Dr. Pallavi Vashisth Dept. of Pedodontics, Institute of
Dental Sciences, Bareilly
Email: [email protected]
Received: 17/02/2015 Accepted: 06/07/2015
P
Revascularization of a necrotic, infected, immature permanent molar with apical periodontitis: a case report ______________________________________________Vashisth P et al.
J Dent Specialities.2015;3(2):180-182 181
and irrigated copiously with 1.25% sodium
hypochlorite and dried with sterile paper points. A
creamy paste of equal proportions of metronidazole,
ciprofloxacin and cefclor mixed with sterile water
was applied to canal space. The access cavity was
closed with cotton pellets and intermediate
restorative material. The patient was asymptomatic
when he returned for follow up treatment. The
antibiotic paste was intact in the canal space and was
irrigated away using 1.25% NaOCl and sterile water.
No instrumentation of the canal space was
performed. The apical tissues beyond the confines of
the root canal were stimulated with sterile endodontic
file to induce bleeding into the canal space. The
blood clot was allowed to reach a level that
approximated the cementoenamel junction. A cotton
pellet moist with sterile water was applied over the
blood clot. After this procedure permanent restoration
with Glass Ionomer Cement was placed. At the 3-and
6 month follow- up evaluation, the patient was
asymptomatic. (Fig 2) One year from the time of
blood clot induction the tooth remained
asymptomatic, with normal limits for percussion,
palpation, pocket probing depths, and mobility.
Radiographs revealed normal periapical structures
with continued root development, and thickening of
lateral aspects of dentinal walls of the root canals,
reinforcing and strengthening the root. (Fig 3)
Fig. 1: Preoperative radiograph showing carious
36, with open apices.
Fig. 2: 6 month follow- up showing continued root
development.
Fig. 3: Radiograph at 12 months showing
continued root development with apical
constriction.
DISCUSSION
This report demonstrates the potential of non-vital
infected teeth to undergo the procedure of
revascularization and the same should be undertaken
to avoid the undesired results of the conventional
treatment options available. The open apex is
difficult or impossible to seal with conventional root
filling methods because of the absence of an apical
stop. Furthermore, the arrested development of the
dentinal walls at the time of pulp necrosis leaves a
weak tooth with thin dentinal walls that are
susceptible to fracture.(2) Bunchs and Trope in 2004
demonstrated the advantages of this treatment
modality, which resulted in a radiographically
apparent normal maturation of the entire root versus
an outcome of only a calcific barrier formation at the
apex after conventional calcium hydroxide- induced
apexification.6
The rationale of revascularization is that if a sterile
tissue matrix is provided in which new cells can
grow, pulp vitality can be reestablished.3 It is known
that the infection control of microbial contamination
from the root canal system is a precondition for
successful root canal treatment and that the primary
goal should be reduce the microbial load to a low
level where tissue healing can occur.7 Various
combinations of topical antibiotics have the ability to
disinfect carious dentin and necrotic, infected root
canals. One combination that is effective against the
bacteria commonly found in infected root canals is
the use of ciprofloxacin, metronidazole and cefaclor.8
But contradictory findings had been reported by
Bezerra da Silva LA et al who evaluated in vivo the
revascularization and the apical and periapical repair
after endodontic treatment using 2 techniques for root
canal disinfection (apical negative pressure versus
apical positive pressure irrigation plus triantibiotic
intracanal dressing) suggesting that the use of intra
canal antibiotics may not be necessary.7
Different mechanism could be attributed to continued
development of root: remnants of vital pulp cells at
Revascularization of a necrotic, infected, immature permanent molar with apical periodontitis: a case report ______________________________________________Vashisth P et al.
J Dent Specialities.2015;3(2):180-182 182
the apical end of the root canal, presence of
multipotent dental pulp stem cells,9 stem cells from
periodontal ligament which can proliferate within the
root canal,10,11 stem cells from apical papilla,12,13 and
presence of blood clot which being a rich source of
growth factors could play an important role in
regeneration.14 The elongation of the root occurs by
apposition of newly generated cementum – like tissue
termed “intracanal cementum”. The generation of this
tissue may occur despite the presence of
inflammatory infiltration at the apex or in the canal.15
There are several advantages of revascularization as
observed from this as well as from the past studies. It
requires a shorter treatment time, after control of
infection, it can be completed in a single visit. It is
also very cost- effective, because, because the
number of visits is reduced and no additional material
is required. Obturation of the canal is not required
unlike in calcium hydroxide induced apexification,
with its inherent danger of splitting the root during
lateral condensation. However the biggest advantage
is that of achieving continued root development and
strengthening of the root as a result of reinforcement
of lateral dentinal walls with deposition of new
dentin/ hard tissue.3
The procedure is simple and may in near future
replace the traditional treatment options including
hard tissue barrier via calcium hydroxide or an
artificial hard tissue barrier of MTA. We need to be
constantly in touch with current concepts of
advancements, take maximum advantage of the same,
improve the standard of our specialty and serve the
community in a better way.
REFERENCES 1. Thibodeau B, Teixeira F, Yamauchi M, Caplan DJ,
Trope M. Pulp revascularization of immature dog teeth
with apical periodontitis. J Endod. 2007;33:680-89.
2. Thibodeau B. Case report: Pulp revasculrization of a
necrotic, infected, immature, permanent tooth. Ped
Dent. 2009;31:145-48.
3. Shah N, Logani A, Bhaskar U, Aggarwal V. Efficacy
of revascularization to induce apexification/
apexogenesis in infected, nonvital, immature teeth: A
pilot clinical study. J Endod. 2008;34:919-25.
4. Ostby BN. The role of the blood clot in endodontic
therapy: an experimental biologic study. Acta Odontol
Scan. 1961;120:324- 53.
5. Rule DC, Winter GB. Root growth and apical repair
subsequent to pulpal necrosis in children. Br Dent J.
1966;120:586-90.
6. Banchs F, Trope M. Revascularization of an immature
permanent teeth with apical periodontitis: new
treatment protocol? J Endod. 2004;30:196-200.
7. Da Silva LAB, Nelson- Filho P, da Silva RAB, Flores
DSH. Revasculrization and periapical repair after
endodontic treatment using apical negative pressure
irrigation versus conventional irrigation plus
triantibiotic intracanal dressing in dogs’ teeth with
apical periodontitis. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2010;109: 779-87.
8. Sato T, Hoshino E, Uematsu H, Noda T. In vitro
antimicrobial susceptibility to combinations of drugs
on bacteria from carious and endodontic lesions of
human deciduous teeth. Oral Microbiol Immunol.
1993;8:172-76.
9. Gronthos S, Brahim J, Li W et al. Stem cell properties
of human dental pulp stem cells. J Dent Res. 2002;
81:531- 35.
10. Lieberman J, Trowbridge H. apical closure of non vital
permanent incisor teeth where no treatment was
performed: case report. J Endod. 1983; 9: 257- 60.
11. Nevin A, Wrobel W, Valachovic R, Finkelstein F. hard
tissue induction into pulpless open- apex teeth using
collagen- calcium phosphate gel. J Endod. 1977;
3:431-33.
12. Krebsbach P, Kuznetsov SA, Satomura K, Emmons
RV, Rowe DW, Robey PG. Bone formation in vivo:
comparison of osteogenesis by transplanted mouse and
human marrow stromal fibroblasts. Transplantation.
1997: 63:1059-69.
13. Gronthos S, Mankani M, Brahim J, Robey PG, Shi S.
Postnatal human dental pulp stem cells (DPSCs) in
vitro and in vivo. Proc Natl Acad Sci USA. 2000; 97:
13625-30.
14. Wang Q, Lin XJ, Lin ZY, Liu GX, Shan XL.
Expression of vascular endothelial growth factor in
dental pulp of immature and mature permanent teeth in
human. Shanghai Kou Qiang Yi Zue. 2007;16:285- 89.
15. Wang X, Thibodeau B, Trope M, Lin LM, Huang GTJ.
Histologic characterization of regenerated tissues in
canal space after revitalization/revascularization
procedure of immature dog teeth with apical
periodontitis. J Endod. 2010;36: 56-63.
How to cite this article: Vashisth P, Vatsala V, Naik S, Singh
MG. Revascularization of a necrotic, infected, immature permanent
molar with apical periodontitis: a case report. J Dent Specialities, 2015;3(2):180-182.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
_________________________________________________________________________Case Report
J Dent Specialities.2015;3(2):183-187 183
Incidental finding of dentigerous cyst - a case report
Pulivarthi Sushma1, Sowbhagya M.B2, Balaji P3, Mahesh Kumar T.S4
ABSTRACT In the jaws, the most common type of developmental odontogenic cyst is dentigerous
cyst, mostly affecting the impacted mandibular third molars and permanent maxillary
canines. They are often noted as an incidental finding on radiographs as unilocular
radiolucency with well-defined sclerotic border which encircles the crown of an
unerupted tooth as most of these dentigerous cysts are clinically asymptomatic. Long
standing cases of dentigerous cysts can progress to either ameloblastoma or squamous
cell carcinoma or mucoepidermoid carcinoma. Henceforth, an early clinical and
radiographic detection of the cyst plays a vital role so that apt treatment modalities can be
carried out which will prevent or decrease the morbidity. With this above background, we
hereby report an enticing case of dentigerous cyst which was incidentally observed in
conventional radiographs and to evaluate further extension and nature of lesion, a
conebeam computed tomography (CBCT) of jaw was taken.
Key words: Dentigerous cyst, Impacted mandibular third molars, Incidental finding,
Cone beam computed tomography
INTRODUCTION
n the jaws, the most common type of
developmental odontogenic cyst is dentigerous
cyst and it encompasses for about 20-24% of all
epithelium-lined cysts of the jaws.1,2,3 In the general
population their incidence has been estimated at 1.44
cysts for every 100 unerupted teeth.4 Dentigerous
cysts occur in a wide range of age group with a peak
frequency of 2nd to 4th decades of life.5 The exact
etiopathogenesis dentigerous cysts remain unknown,
but most of the authors suggest a developmental
origin from the tooth follicle.6 They are often noted
as an incidental finding on radiographs as unilocular
radiolucency with well-defined sclerotic border
which encircles the crown of an unerupted tooth as
most of the dentigerous cysts are clinically
asymptomatic. Diagnosis of a dentigerous cyst is
straight forward in majority of the cases, but
radiographically a ‘typical’ dentigerous cyst should
be differentiated from a keratocystic odontogenic
tumour (KCOT) [an odontogenic keratocyst] and
unicystic ameloblastoma.7 Dentigerous cysts over a
period of time can progress to ameloblastoma or
squamous cell carcinoma or mucoepidermoid
carcinoma.8,9,10,11 Therefore, an early clinical and
radiographic recognition of the cyst plays a vital role
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DOI: 10.5958/2393-9834.2015.00012.1
so that apt treatment modalities can be carried out
which will prevent or decrease the morbidity.
CASE REPORT
A middle aged female patient (30 years) reported
with a chief complaint of pain in the lower front tooth
region since one month to the department of oral
medicine and radiology. Pain was insidious in onset,
mild, intermittent and dull aching type. On
examination all vital signs were within normal limits
and no gross asymmetry of the face was noted. On
intraoral examination gingival recession; gingival
bleeding on probing and periodontal pocket was
present in relation to 31 and 41 and hard tissue
examination revealed no abnormality. Based on
history and clinical findings a working diagnosis of
chronic generalized gingivitis with localized
periodontitis in relation to 31, 41 was made and
subsequently patient was subjected to routine
radiographic investigations.
Intraoral periapical radiograph revealed alveolar
crestal bone loss in relation to 31 and 41. Digital
panoramic radiograph revealed presence of well-
defined radiolucency with sclerotic border
surrounding crown of the unerupted tooth in relation
to 38 at cemento-enamel junction level. The
radiolucency appeared oval in shape extending
antero-posteriorly from distal root of 36 to the crown
of 38 and supero-inferiorly extending from 5mm
below the alveolar crest in relation to 37 till lower
border of mandible. Based on these imaging findings,
a radiographic diagnosis of dentigerous cyst in
relation to 38 was given and differential diagnosis of
unicystic ameloblastoma and keratocystic
odontogenic tumor were considered.
1Post Graduate Student, 2Reader, 3Head and prof, 4Senior lecturer,
Department of Oral Medicine and
Radiology, Rajarajeswari Dental College and Hospital, Bangalore,
Karnataka, India.
Address for Correspondence:
Dr. Pulivarthi Sushma Post Graduate Student
Department of Oral Medicine and
Radiology, Rajarajeswari Dental College and Hospital, Bangalore,
Karnataka, India
Email:
Received: 19/01/2015
Accepted: 20/05/2015
I
Incidental finding of dentigerous cyst - a case report ________________________________________Sushma P et al.
J Dent Specialities.2015;3(2):183-187 184
Based on radiographic diagnosis which was obtained
through preliminary radiological examination patient
was subjected to CBCT of jaw to evaluate further
extension and nature of lesion of mandibular left
third molar region. Additional finding revealed
lingual expansion with severe thinning and
perforation of the lingual cortical plate. The buccal
cortex appeared intact with mild expansion. The
mandibular canal outlines were lost along the lesion
with the canal displaced inferiorly along the
mandibular base. No evidence of root resorption was
noted in relation to distal root tip of 36 and the roots
of 37 appeared within the lesion. The CBCT findings
were suggestive of a dentigerous cyst in relation to 38
All the parameters were within normal limits on
routine hematological investigations. After obtaining
patient’s consent the cyst was treated by surgical
enucleation along with the removal of impacted tooth
under local anesthesia and specimen was subjected to
histopathological examination. H & E section
revealed a dense connective tissue stroma with
proliferating fibroblasts, numerous blood vessels
lined by endothelial cells and few inflammatory cell
infiltrate. We arrived at final diagnosis of dentigerous
cyst with all the radiographic and histopathological
findings.
Fig 1: Intraoral view
Fig. 2: Orthopantomogram (Pre-operative)
Fig. 3(a);
Fig. 3(b);
Fig. 3(c)
Fig. 3(a); 3(B); 3(C): CBCT- Cross Section along the
Long Axis of 38 – Fused and Conical Root
Incidental finding of dentigerous cyst - a case report ________________________________________Sushma P et al.
J Dent Specialities.2015;3(2):183-187 185
Fig. 4(a)
Fig. 4(b)
Fig. 4(c)
Fig 4(a); 4(b); 4(c): CBCT- Sections along 36, 37 Reveal
Intact Root with No Evidence of Resorption
Fig. 5: CBCT- Axial Section
Fig. 6: CBCT- Bucco-Lingual Section
Fig. 7: CBCT- Cross Section of 38
Incidental finding of dentigerous cyst - a case report ________________________________________Sushma P et al.
J Dent Specialities.2015;3(2):183-187 186
Fig. 8: CBCT- 3 D reconstruction
Fig. 9: Surgical enucleation
Fig. 10: Orthopantomogram (Post-operative)
Fig. 11: Photomicrograph 4X
DISCUSSION
In the jaws, the most common type of developmental
odontogenic cyst is dentigerous cyst and it
encompasses for about 20-24% of all epithelium-
lined cysts of the jaws.1,2,3 Worldwide, incidence has
been estimated at 1.44 cysts for every 100 unerupted
teeth.4 The exact etiopathogenesis of dentigerous
cysts remain unknown, but most of the authors
suggest a developmental origin from the tooth
follicle6. The development of dentigerous cyst is due
to fluid accumulation between the epithelium and the
crown of an unerupted tooth.2,3,12
Dentigerous cysts occur in an assorted range of age
group with a peak frequency of 2nd to 4th decades of
life and in the current case it occurred in the 3rd
decade.5 Generally mandibular third molars are the
most frequently affected, which was seen in our case,
followed by the maxillary canine, mandibular second
premolar and maxillary third molar.5 Most of these
follicular cysts are asymptomatic consequently they
are often noted as an incidental finding on
radiographs as in the present case.7
Radiographically it may show unilocular
radiolucency in association with the crowns of
unerupted teeth, having a well-defined sclerotic
margins as seen in our case. Trabeculations are
seldom seen and may give a false impression of
multilocularity. Dentigerous cyst show three different
types of radiological variations; which are as follows:
central, lateral and circumferential type. The crown is
enveloped symmetrically in central variety. The
lateral type of dentigerous cyst is a radiographic
appearance as a result of dilatation of the follicle on
one aspect of the crown. Ultimately in
circumferential dentigerous cyst entire tooth appears
to be enveloped by cyst. Present case showed central
variety of dentigerous cyst.13
The differential diagnosis may also include
keratocystic odontogenic tumour and unicystic
ameloblastoma. A keratocystic odontogenic tumor is
less likely to resorb teeth which may attach farther
apically on the root instead at the cementoenamel
junction. Significantly KCOT does not expand the
bone to the same degree as a dentigerous cyst. It is a
challenge to differentiate dentigerous cyst from a
small unicystic ameloblastoma if there are no internal
structure. There may be evidence of one or several
locules although these are few and tend to remain
faint or poorly calcified. Unicystic ameloblatoma
may show knife edge pattern of root resorption of the
apical one third of the adjacent erupted second or first
molar. On axial CT scans, most of the dentigerous
cysts typically expand in only one direction, usually
buccal cortical plate because bone is thinner at this
site. With more extensive ameloblastomatous change,
expansion may be toward buccal as well as lingual
Incidental finding of dentigerous cyst - a case report ________________________________________Sushma P et al.
J Dent Specialities.2015;3(2):183-187 187
cortical plates and small locules at the margin of the
lesion are suggestive of ameloblastomatous change.14
Many dentigerous cysts show evidence of acute and
chronic inflammation in their walls. Moreover, the
passage of desquamated epithelial cells and
inflammatory cells into the cyst cavity may
contribute to increased intracystic osmotic tension
and thus leads to further expansion of the cyst. As the
cyst expands, there may be some compensatory
epithelial proliferation to cover the greater surface
area of connective tissue according to Browne
(1975). Moreover, Stenman et al (1986) also have
shown that dentigerous cyst epithelium has little
capacity for invitro growth which are also found in
our case.13
The main treatment modality for dentigerous cyst is
enucleation and also removal of the associated tooth
which was done in our case. Marsupialization is
performed in case of large dentigerous cysts to avoid
neurosensory dysfunction and pathological fracture.
Untreated dentigerous cysts can evolve into
ameloblastoma or squamous cell carcinoma or
mucoepidermoid carcinoma.8,9,10,11 Many of these
dentigerous cyst can attain substantial size without
any notice to the patient hence, an early intervention
in terms of clinical and radiographic detection of the
cyst plays a vital role to implement appropriate
treatment strategies thereby, to prevent or decrease
morbidity.
REFERENCES: 1. Benn A, Altini M. Dentigerous cysts of inflammatory
origin. A cliniccpathologic study. Oral Surg Oral Med
Oral Pathol Oral Padiol Endod 1996;81:203-09.
2. Da Silva TA, De Sa AC, Zardo M, Consolaro A, Lara
VS. Inflammatory follicular cyst associated with an
endodontically treated primary molar: A case report.
ASDC J Dent Child 2002;69:271-74.
3. Shaw W, smith M, Hill F. İnflammatory follicular cyst.
ASDC J Dent Child 1980;47:97-101.
4. Mourshed F. A roentogenographic study of
dentigerous cysts. Oral Surg Oral Med Oral Pathol
1964;18:466-73.
5. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral
and Maxillofacial Pathology. 3rd ed. Philadelphia,
W.B.Saunders; 1995:493-540.
6. Regezi JA, Sciubba JJ, Jordan RCK. Oral Pathology:
clinical pathologic correlations. 4th ed, WB
Saunders;2003:241-54.
7. Satya Bhushan SNVV, Rao NM, Navatha M, Kumar
BK. Ameloblastoma Arising from A Dentigerous Cyst-
A Case Report. J Clin Diagn Res. 2014; 8: ZD23-25.
8. Banderas JA, Gonzalez MA, Ramirez F, Arroyo A.
Bilateral mucous cell containing dentigerous cysts of
mandibular third molars: Report of an unusual case.
Arch of Med Res, 1996;27:327-29.
9. Johnson LM, Sapp JP, McIntire DN. Squamous cell
carcinoma arising in a dentigerous cyst. J Oral
Maxillofac Surg. 1994;52:987–90.
10. Eversole LR, Sabes WR, Rovin S. Aggressive growth
and neoplastic potential of odontogenic cysts. With
special reference to central epidermoid and
mucoepidermoid carcinomas. Cancer. 1975;35:270–82.
11. Leider AS, Eversole LR, Barkin ME. Cystic
ameloblastoma. Oral Surg Oral Med Oral Pathol. 1985;
60:624–30.
12. Ko KSC, Dover DG, Jordan RCK. Bilateral
Dentigerous Cysts - Report of an Unusual Case and
Review of the Literature. J Can Dent Assoc. 1999;65:
49-51.
13. Shear M, Speight P. Cysts of the Oral and
Maxillofacial Regions. 4th ed. Australia: Blackwell
Munksgaard. 2007:p65.
14. Stuart C. White, Michael J, Pharoah. Oral radiology:
principles and interpretation. 6thed. New Delhi. Mosby.
2004:p368.
How to cite this article: Sushma P, Sowbhagya MB, Balaji P,
Mahesh Kumar TS. Incidental finding of dentigerous cyst - a case
report. J Dent Specialities,2015;3(2):183-187.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
_________________________________________________________________________Case Report
J Dent Specialities.2015;3(2):188-191 188
Management of root resorption in maxillary first molar- radectomy
Anshdeep Singh1, Himanshu Aeran2, Seema Dixit3, Saurabh Arora4, Ashish Chaoudhary5
ABSTRACT Preservation of tooth is one of the major goals of an Endodontist. This goal can be
acquired either by non surgical or surgical approach. Root resection is one of the surgical
approaches for preservation of molars with furcation involvement. This procedure results
in a unique environment which is dictated by the contours of the remaining roots and the
residual furcation between them. Root resorption is a viable treatment option to salvage
and retain a part of multirootedteeth. This case report illustrates prognosis of root
resection after completion of endodontic therapy for managing a case of root resorption.
This case shows external root resorption of the distobuccal root of right maxillary first
molar. Due to strategic value of maxillary first molar, it was decided to employ root
resection. After completion of endodontic therapy root resection was carried out. After 6
months, the absence of periradicular radiolucent lesions, periodontal pocket, pain, and
swelling indicated a successful outcome of root resection.
Keywords: Endodontist, Multirooted teeth, Periradicular, Distobuccal, Resorption
INTRODUCTION
he tooth, its pulp, and its supporting structures
must be viewed as a biological unit. The
interrelationship among these structures influence
each other during health, function and diseases.1
Pulp tissue succumbs to degeneration by way of a
multitude of insults, such as caries, restorative
process, chemical and thermal insults, trauma and
periodontal disease. When products from pulp
degeneration reach the supporting periodontium,
rapid inflammatory responses can ensure that are
characterized by bone loss, tooth mobility and
sometimes sinus tract formation.
Periodontal disease by contrast, is a slowly
progressive disease that may have a gradual atrophic
effect on dental pulp resulting from dental plaque
accumulation on external tooth surface.2
Simultaneous existence of pulpal problems and
inflammatory periodontal disease can complicate
diagnosis and treatment planning and affect the
sequence of care to be performed.3 The relationship
between the periodontium and the pulp was first
discovered by Simring and Goldberg in 1964.4
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Periodontium is anatomically interrelated with the
dental pulp by virtue of apical foramina and lateral
canals create pathways for exchange of noxious
agents between the two tissue compartments. Lesions
of the periodontal ligament and adjacent alveolar
bone may originate from infections of the
periodontium or tissues of dental pulp.5
Resorptive processes involving the root surface, and
treatment measures aimed at managing periodontal
disease enhance this potential as the accompanying
exposure of dentinal tubules establishes passage
across the body of the tooth structure. Hence,
inflammatory symptoms often seen as typical of
periodontal disease including deep periodontal
pockets with or without swelling and suppuration of
the marginal gingiva, increased tooth mobility and
angular bony defects may also represent symptoms of
a pathological condition present in the root canal
system of the affected tooth.6
The management of molar teeth exhibiting furcation
involvement has always been a challenge to the
dentist and usually involves combining restorative
dentistry, endodontics and periodontics so that the
teeth are retained in whole or in part.
Root resection has been widely used successfully to
retain teeth with furcation involvement as well as
roots exhibiting resorption and loss of periodontal
apparatus. It is important to consider the factors such
as angulation of the tooth, length and curvature of
roots, bone support of retained roots/root before
deciding to undertake any root resection procedure.6
In this case report amputation of distobuccal root of
maxillary first molar is presented. Root resection
1Senior lecturer, 3Professor and Head, 4Reader, 5Post graduate student Department of Conservative Dentistry
and Endodontics, Seema Dental
College and Hospital, Rishikesh, Utarakhand 2Director Principal, Seema Dental
College and Hospital
Address for Correspondence:
Dr Anshdeep Singh Sr Lecturer
Department of Conservative Dentistry
and Endodontics Seema Dental College and Hospital
Veerbhadra Road, Pashulok
Rishikesh, Uttrakhand Email: [email protected]
Received: 17/02/2015 Accepted: 20/05/2015
T
Management of root resorption in maxillary first molar- radectomy ___________________________Singh A et al.
J Dent Specialities.2015;3(2):188-191 189
therapy is said to be a treatment option for molars
with periodontal, endodontic, restorative or prosthetic
problems. It is mentioned that commonly sighted
indications for root resection are severe bone loss,
class II or class III furcation involvement, severe
recession or dehiscence, inability to fill a canal, root
fracture, root resorption, and root decay. In a
maxillary molar, root respective therapy can be used
when attachment loss, caries or a fracture involving
furcation area.7
Root resection can be an alternative treatment in a
molar tooth having endodontic-periodontal problem
such as true combined lesion where root resection
may allow changing the root configuration of the part
of the tooth to be saved.8
CASE REPORT
A 26 year old female patient reported to the
department of Conservative dentistry and
Endodontics, Seema Dental College and Hospital,
Rishikesh, with the chief complaint of food lodgment
and pain in right maxillary posterior teeth. On
examination it was found that gingival recession was
present in relation to distobuccal root of left
maxillary first molar, along with furcation
involvement.
Detailed history revealed that patient used abrasive
tooth powder for cleaning teeth for last four years
which resulted in gingival recession and periodontal
involvement causing bone loss. Tooth was nonvital
and did not show any response to thermal and
electrical pulp vitality tests.
On radiographic examination (Fig-1), root resorption
was visible in case of distobuccal root of maxillary
and (periodontal) bone loss was visible all around the
distobuccal root where the mesiobuccal root and
palatal root were healthy. Grade I mobility was seen
in maxillary first molar.
Phase I therapy was carried out which included
thorough scaling, curettage, root planning. The tooth
was prepared for endodontic treatment. After
administering local anesthesia rubber dam application
was done. Access cavity was prepared, working
length was established and biomechanical preparation
was carried out after locating the two mesiobuccal,
distobuccal and the palatal canal. After complete
disinfection of the root canal system, obturation was
carried out in the mesiobuccal and palatal canals.
This was followed by post endodontic restoration of
silver amalgam.
After 10 days of completion of root canal treatment
under coverage of local anaesthesia, a full
mucoperiosteal flap was raised in relation to
maxillary right molar. (Fig-2)
The furcation area was cleaned and identified by
passing a needle through the buccal trifurcation and
distobuccal root was resected by making horizontal
cut (from distal part up to the furcation area).
Resection of distobuccal root was carried out using
vertical cut method.9 (Fig-3) Furcation area was
slightly trimmed to ensure that no residual debris
remained. Contouring was done to make it a self
cleansing area. The occlusion was checked to
eliminate any discrepancy and minimize the occlusal
load. (Fig-4,5)
Fig. 1: Preoperative
Fig. 2: Flap reflection
Management of root resorption in maxillary first molar- radectomy ___________________________Singh A et al.
J Dent Specialities.2015;3(2):188-191 190
Fig. 3: Root Resection
Fig. 4: Resected Distobuccal Root
Fig. 5: Postoperative
DISCUSSION
The terms “root amputation” and “hemisection” are
collectively called as “root resection”.10 Root
resection involves removing one or more roots of the
tooth to maintain the functioning of the rest of the
tooth. Root resection is dependent on selection of the
tooth. According to Newell the advantage of the
resection is the retention of some or the entire tooth.11
Success of root resection procedures depends, to a
large extent, on proper case selection. It is important
to consider the factors such as angulation of the tooth,
length and curvature of roots, bone support of
retained root and feasibility of endodontics and
restorative dentistry in the root/roots to be retained;
before deciding to undertake any of the root
separation and resection procedures.6
Root-resection therapy is a treatment option for
molars with periodontal, endodontic, restorative, or
prosthetic problems.12 Because root resection is very
technique sensitive and complex, proper case
selection is essential.13 The prognosis of root
resection has been well documented in previous
studies. According to the standardized reports on 11
root resection of Buhler, 89% of root resected teeth
survived over a 7-year period. However, Carnevale et
al reported a 6.9% failure rate over a 10- year period.
In a limited meta-analysis using common denomina-
tors of time of observation and criteria of failure as
12 defined by Langer et al, Buhler reported that the
failure rate for teeth treated by root-resection, over a
seven-year observation period, was 11%.
Root resection has been used successfully to retain
teeth with furcation involvement. The disadvantage
being the root surfaces in the furcation area become
more susceptible to caries. Often a favorable result
may be negated by decay after treatment, failure of
endodontic therapy due to any reason and occlusal
discrepancies involving the prosthesis to name a few.
The prognosis of root resection is same as for routine
endodontic therapy provided that the root resection is
of acceptable design. With recent advancement in
endodontics, periodontics and restorative dentistry,
root resection has received renewed acceptance.
Traditional wisdom was based on the concept of
trying to save the tooth by all means necessary.
However with inception of dental implants, a
completely new avenue has been opened in the
treatment planning process.
This has created a new debate. Some advocate the
traditional approach while others have adopted a
more aggressive approach and prefer to extract and
replace a compromised tooth with an implant
restoration.
CONCLUSION
Root-resection therapy is still a valid treatment option
for molars with furcation involvement and severe
bone loss. Root resection should be considered as
Management of root resorption in maxillary first molar- radectomy ___________________________Singh A et al.
J Dent Specialities.2015;3(2):188-191 191
another weapon in the arsenal of the dental surgeon,
determined to retain and not to remove the natural
teeth.
BIBLIOGRAPHY 1. Grossman LI, Oliet S, Delrio C. Endodontic practice.
11th edition. 1988:313-22.
2. Newman, Takei, Carranza. Clinical periodontology. 9th
edition. 2002:840-45.
3. Cohen S, Hargreaves KM. Pathways of pulp. 9th
edition. 2006:650-68.
4. Newman, Takei, Carranza. Clinical periodontology. 9th
edition. 2002:846-50.
5. Simring M, Goldberg M. The pulpal pocket approach:
Retrograde periodontitis. J Periodontol.1964;35:22–48.
6. Meng HX. Periodontic-endodontic lesions. Ann
Periodontol.1999;4:84-90.
7. Simring M, Goldberg M. The pulpal pocket approach:
Retrograde periodontitis. J Periodontol.1964;35:22–48.
8. John L. Clinical periodontology and implant dentistry.
4th edition. Oxford bone 2003:705-20.
9. John L. Clinical periodontology and implant dentistry.
4th edition. Oxford bone 2003:721-30.
10. Hempton T, Leone C. A review of root respective
therapy as a treatment option for maxillary molars. J
am Dent assoc 1997;128:449-55.
11. Weine FS. Endodontic therapy. 6th edition 2004:110-
20.
12. Basaraba N. Root amputation and tooth hemisection.
Dent clin North Am 1969;13:121-32.
13. Newell DH. The role of the prosthodontist in restoring
root resected molars; a study of 70 molar root
resections. J Prosthet dent 1991;65:7-15.
How to cite this article: Singh A, Aeran H, Dixit S, Arora A,
Chaoudhary A. Management of root resorption in maxillary first
molar- radectomy. J Dent Specialities,2015;3(2):188-191.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
_________________________________________________________________________Case Report
J Dent Specialities.2015;3(2):192-194 192
Occlusal guiding flange prosthesis for management of
hemimandibulectomy- a case report
Sumit Pathak1, Saloni Deol2, Amit Jayna3
ABSTRACT Surgical resection of the mandible due to presence of benign or malignant tumor is the
most common. Depending upon the location and extent of the tumor in the mandible,
various surgical treatment modalities like marginal, segmental, hemi, subtotal, or total
mandibulectomy can be performed. Mandibular discontinuity defects present a major
challenge to the rehabilitation team and to maxillofacial prosthodontist. Discontinuity of
mandible after resection destroys balance and symmetry which leads to altered
mandibular movements and deviation of the residual fragment towards the defective
side. Variety of materials and techniques have used for the construction of prosthetic
replacement of the acquired surgical defects.
This case report describes prosthodontic management of a patient who has undergone
hemi-mandibulectomy with mandibular guide flange prosthesis. To aid in moving the
mandible normally without deviation during functions like speech and mastication.
Keywords: Hemimandibulectomy, Guiding flange, Maxillofacial prosthesis
INTRODUCTION
ariety of materials and techniques have used for
the construction of prosthetic replacement of the
acquired surgical defects. The cosmetic, functional,
and psychosocial results of oral cancer treatment may
affect variety of functions, including speech,
deglutition, management of oral secretions, and
mastication. Thus, maxillofacial prosthetic
rehabilitation helps to restore the head and neck
cancer patient’s oral functions and cosmetics
following surgery.1 Acquired defects of the orofacial
structures must be analyzed as to the specific cause
and the consequent objectives of rehabilitation.
Mandibular discontinuity defects present a major
challenge to the rehabilitation team and to
maxillofacial prosthodontist. Discontinuity of
mandible after resection destroys balance and
symmetry which leads to altered mandibular
movements and deviation of the residual fragment
towards the defective side. This would hamper the
aesthetic and psychological comfort along with
masticatory function2.
A ram or guide plane to maxillary teeth that oppose
the non resected side of mandible helps patient to
achieve consistent closure to an intercuspal position.
Guide flange prosthesis (GFP) is a mandibular
conventional prosthesis designed for the patient who
has undergone hemimandibulectomy and able to
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achieve an appropriate mediolateral position of the
mandible but is unable to repeat this position
consistently for adequate mastication2. Guiding
Flange made of acrylic polymers which lacks the
principles of Removable Partial Denture design may
affect the longevity of the remaining teeth. This case
report describes prosthodontic management of a
patient who has undergone a hemimandibulectomy2.
CASE REPORT
A 39 year old male reported to the Department of
prosthodontics with a chief complaint of difficulty in
mastication and speech. He had a unilateral
discontinuity mandibular defect on the right side due
to surgery for squamous cell carcinoma. The surgery
was performed 8 months back followed by radiation.
Extraoral examination showed facial asymmetry with
mandibular deviation to the right side (Fig-1,2).
Clinical examination revealed severe deviation of the
mandible towards the resected side, with lack of
proper contact between the maxillary and the
mandibular teeth. Intra oral examination showed
missing teeth in the right side of mandible.
The mandibular defect was classified as Cantor and
Curtis Class VI i.e. resection of the lateral portion of
the mandible without subsequent augmentation to
restore form and function3. A maxillary and
mandibular impression was made by using
irreversible hydrocolloid. The casts were poured with
Type III dental stone (Fig-3). A maxillomandibular
record was made by manually assisting the mandible
into the centric occlusion. The maxillary and
mandibular cast was mounted on a articulator.
The prosthesis was fabricated on the non defect (left)
side. The design included the guidance flange on the
buccal side and the supporting flange on the lingual
side. The retention was provided by the interdental
1,2PG student, 3Professor and Head,
Dept. of prosthodontics, ITS Dental College, Hospital and Research
Centre, Greater NOIDA
Address for Correspondence
Dr. Sumit Pathak
PG student, Dept of prosthodontics ITS Dental College, Hospital and
Research Centre, Greater NOIDA
Email: [email protected]
Received: 02/03/2015
Accepted: 14/08/2015
V
Occlusal guiding flange prosthesis for management of hemimandibulectomy- a case report ______Pathak S et al.
J Dent Specialities.2015;3(2):192-194 193
clasp, engaging the premolars and the molars (Fig-4).
The guide flange extended superiorly and diagonally
on the buccal surface of the molars and the
premolars, allowing the normal horizontal and
vertical overlap of the maxillary teeth (Fig-5). The
guide flange was sufficiently blocked out, so that it
would not traumatize the left maxillary teeth and the
gingiva when the patient closed his mouth. Care
should be taken to preserve the buccal-surface
indentations of the opposing maxillary teeth which
were guiding the mandible in a final definite closing
point during mastication. The flange height was
adjusted in such a way that it guided the mandible
from large opening position (in practical limits of the
height of the buccal vestibule) to the maximum
intercuspation in a smooth and unhindered path. The
prosthesis was delivered and post-insertion
instructions were given.
Fig. 1: front profile of patient
Fig. 2: lateral profile of patient
Fig. 3: impressions of the remaining mandibular
teeth
Fig. 4: guiding flange appliance with retentive
clasp
Fig. 5: buccal extension of GFA
Occlusal guiding flange prosthesis for management of hemimandibulectomy- a case report ______Pathak S et al.
J Dent Specialities.2015;3(2):192-194 194
DISCUSSION
Complete rehabilitation of a hemi -mandibulectomy
case is a challenging task, especially due to the lack
of bony foundation on the surgical side. Loss of
mandibular continuity causes deviation of remaining
mandibular segment(s) towards the defect and
rotation of the mandibular occlusal plane inferiorly.
Mandibular deviation toward the defect side occurs
primarily because of the loss of tissue involved in the
surgical resection.2
When a segment of the mandible is removed,
immediate reconstruction is usually recommended to
improve both facial symmetry and masticatory
function. Although techniques for reconstructive
surgery and prosthodontic rehabilitation have
advanced, more than 50% of reconstructed head and
neck cancer patients still report impaired masticatory
function. The GFP can be regarded as a training type
of prosthesis. If the patient can successfully repeat
the mediolateral position, the GFP can often be
discontinued.4
Support for the GFP is no different from that of any
other removable prosthesis, the natural teeth and the
residual alveolar ridge being the primary sources.
Multiple retentive clasps in widely distributed areas
of the arch would be the best approach, but actual
placement would be determined by the position of the
teeth. Retentive elements should be no more rigid
than necessary, but they require a more rigidity with a
decreasing number of teeth.4,5
CONCLUSION
Our main aim was to fabricate interim training device
to guide mandible to unassisted maximum occlusal
contacts. The success of hemimandibulectomy
rehabilitation depends on the nature of surgical
defect, patient's cooperation and prosthetic
management with early physiotherapy program. The
presence of teeth in both the arches creates a better
proprioceptive sense and the prosthesis which re-
educates the mandibular muscles to re-establish an
acceptable occlusal relationship will control the
opening and closing of the mandibular movements
adequately and repeatedly.
REFERENCES 1. Chhuchhar L, Gandhewar MA. Guide Flange
Prosthesis for Management for a Hemimandibulectomy
Patient- A Clinical Case. IOSR. J Dent Med Sci.
2013;8:23-25.
2. Pradhan AV, Dange SP, Vaidya SA. Mandibular
repositioning in a hemimandibulectomy patient using
guide flange prosthesis: A Case Report. J Adv Med
Dent Scie 2014;2(2):161-65
3. Cantor R, Curtis TA. Prosthetic management of
edentulous mandibulectomy patients -Part II, Clinical
Procedures J Prosthet Dent 1971;25:546-55.
4. Patil PG, Patil. SP. Guiding flange prosthesis for a
patient treated for amealoblastoma- Case Report. J Adv
Prosthodont. 2011;3:172-76.
5. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith
CR, Koumjian JH, Arbree NS. Classification system
for partial edentulism. J Prosthodont 2002;11:181-93.
How to cite this article: Pathak S, Deol S, Jayna A. Occlusal guiding flange prosthesis for management of hemimandibulectomy
- a case report. J Dent Specialities, 2015; 3(2):192-194.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest related to this study.
_________________________________________________________________________Case Report
J Dent Specialities.2015;3(2):195-198 195
Odontogenic keratocyst of the angle and ramus of the mandible - a case
report
Shaveta Garg1, M.K Sunil2, Ashwarya Trivedi3, Neetu Singla4
ABSTRACT The Odontogenic Keratocyst (OKC), first described by Phillipsen in 1956, has been
reclassified as odontogenic neoplasm and has been renamed as Keratocystic Odontogenic
Tumor (KCOT) as reported in WHO classification of head and neck tumors in 2005.
Odontogenic keratocysts are benign intraosseous tumors of odontogenic origin that occur
most commonly in the jaw. In particular, they have a predilection for the angle and
ascending ramus of the mandible. The recurrent rate of odontogenic keratocyst is 25 – 30
percent. A case of odontogenic keratocyst in 60 years old patient is presented involving
mandibular third molar ramus area which was recurred after 3 years.
Keywords: Keratocyst, Odontogenic, Molar, Ramus
INTRODUCTION
ooth development involves complicated,
multistep interactions between the oral
epithelium and the underlying mesenchymal tissue.
Ectopic teeth can arise when these tissue interactions
during development are affected by developmental
disturbances, iatrogenic activity, or pathological
conditions, such as the presence of a tumor or a cyst.1
Odontogenic keratocysts (OKC) have high recurrence
rates, mitotic counts and epithelial turnover rates, and
are the most aggressive of the odontogenic cysts in
the oral cavity. In addition, unlike most cysts, usually
thought to grow solely due to osmotic pressure, the
epithelium in the OKC appears to have innate growth
potential, which is consistent with a benign tumor.2
Given these features, not observed in common cysts,
such as radicular and dentigerous cysts, the World
Health Organization reclassified OKC as a
keratocystic odontogenic tumor (KCOT) in 2005. We
chose the term OKC instead of KCOT in this report,
because most of references yet contain the former
term. 1
The clinical and radiographic features of OKC are
unspecific: while some may be associated with pain,
swelling, or drainage, most are asymptomatic, and
radiography reveals a well-defined radiolucent area,
which is also characteristic of dentigerous cysts,
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radicular cysts, or residual cysts. Thus, while the
clinical and radiographic features can often be highly
suggestive, they are not diagnostic. This means that
OKC is often misdiagnosed as an ordinary cyst and is
therefore undertreated, resulting in unnecessary
recurrences.2, 3
CASE REPORT
A 60 year old female patient reported to the
department with chief complaint of swelling in the
left lower back teeth region since 15 days. History of
present illness revealed that the swelling was initially
smaller in size but it gradually increased to present
size. There was also the history of swelling in the
same teeth region 3 years back for which she got
surgery done with eventful extraction of teeth in left
lower back teeth region. Now patient again noticed
swelling 15 days back. There was no history of any
trauma or any discharge. No history of any difficulty
in chewing the food. Past medical history revealed
that there was no systemic illness present. Personel
history revealed that patient was vegetarian in diet
and there was no history of any deleterious habit like
smoking, tobacco or betel nut chewing, alcohol etc.
Extraoral examination revealed that there was a
diffuse swelling on left lower side of face i.e approx.
2.5 X 3 cm in size extended anteriorly from line
joining left commissure of lip upto angle of mandible
posteriorly. Superiorly it extended from ala tragus
line inferiorly upto lower border of mandible. The
colour of swelling was same as that of surrounding
skin. On palpation it was soft to firm in consistency,
non-tender, non-compressible, non-fluctuant and
afebrile to touch. (Fig.1)
1PG student, 2Prof. & Head, 3Reader, 4Sr. Lecturer,
Dept of Oral Medicine and Radiology Guru Nanak Dev Dental College and
Research Institute, Sunam (Punjab)
Address for Correspondence:
Dr. Shaveta Garg
PG student, Dept. of Oral Medicine and Radiology, Guru Nanak Dev
Dental College and Research Institute,
Sunam (Punjab) Email: [email protected]
Received: 17/02/2015
Accepted: 05/06/2015
T
Odontogenic keratocyst – a case report ________________________________________________________Garg S et al.
J Dent Specialities.2015;3(2):195-198 196
Intraoral examination revealed that there was
obliteration of buccal vestibule wrt 35, 36 teeth
region. Overlying surface was of same colour as that
of surrounding mucosa. On palpation it was was soft
to firm in consistency, non-tender and no discharge
was present (Fig. 2).Teeth were missing wrt
16,27,33,34,35,36,46 and generalized calculus &
stains were present. On aspiration straw coloured
fluid was present.
With the above clinical findings, provisional
diagnosis of generalized chronic periodontitis and
odontogenic keratocyst wrt 35, 36 was given with
differential diagnosis of unicystic ameloblastoma.
Intraoral periapical radiograph (IOPA) was taken,
which showed a radiolucency wrt 35, 36, 37 teeth
region that extends anteriorly from 35 tooth region
posteriorly upto mesial aspect of 37 tooth region.
Superiorly it extends from alveolar ridge
corresponding to 35, 36 teeth region and inferior
limits are not appreciated (Fig. 3). Mandibular
occlusal topographic radiograph was taken which
revealed normal anatomic landmarks and missing
teeth wrt 33, 34, 35, 36 (Fig. 4). OPG was taken
which showed a well-defined radiolucency was
present wrt left lower molar – ramus area which was
oval in shape with well-defined corticated borders on
its anterior aspect, superior aspect, inferior aspect and
no posterior aspect not well appreciated. Internal
septae was present giving it a multilocular
appearance (Fig. 5) Radiographic diagnosis of
odontogenic keratocyst was given with differential
diagnosis of unicystic ameloblastoma, odontogenic
myxoma, simple bone cyst.
After taking the informed consent of the patient
marsupilization was done under local anesthesia.
Histopathological specimen revealed 8-10 cell thick
parakeratinized stratified squammous epithelium
lining a thin fibrous connective tissue wall. The
epithelial- connective tissue interface was flat. The
luminal surface showed flattened parakeratotic
epithelium which exhibited a corrugated appearance.
The basal layer was composed of palisaded layer of
cuboidal cells with hyperchromatic nucleus. At
palces the cyst epithelium was detached from
underlying fibrous connective tissue wall (Fig. 6)
The overall features were suggestive of odontogenic
keratocyst. So final diagnosis of odontogenic
keratocyst wrt left lower molar – ramus area was
given. The patient was followed up after one month
and the healing was found to be satisfactory with no
tendency for recurrence.
Fig. 1: Extraoral picture showing swelling on left lower
side of face
Fig. 2: Intraoral picture showing obliteration of
vestibule wrt 35, 36 region
Fig. 3: IOPA wrt 35, 36, 37 which showed a
radiolucency that extends anteriorly from 35 tooth
region posteriorly upto mesial aspect of 37 tooth region
Odontogenic keratocyst – a case report ________________________________________________________Garg S et al.
J Dent Specialities.2015;3(2):195-198 197
Fig. 4: Mandibular occlusal topographic radiograph
which revealed normal anatomic landmarks and
missing teeth 33,34,35,36
Fig. 5: OPG which showed a well-defined radiolucency
was present wrt left lower molar – ramus area which
was oval in shape with well-defined corticated borders
and internal septae was present giving it a multilocular
appearance
Fig. 6: Histopathological picture showing epithelial
lining has a hyperchromatic and palisaded basal cell
layer, is 8 to 10 cells thick, has a corrugated
parakeratotic surface, and is detached from the
connective tissues.
DISCUSSION
The odontogenic keratocyst (OKC) is a well-known
pathologic lesion of the jaws derived from rests of the
dental lamina. It represents approximately 10 percent
of all jaw cysts and may occur in a wide age range of
patients. About 70 percent or more cases involve the
mandible, especially in the molar, angle and ramus
regions.2 The present case also involve mandibular
molar - ramus area.
Symptoms such as pain, swelling and drainage may
be present, especially with larger lesions. However,
at least half of all lesions are discovered as incidental
radiographic findings. Due to the propensity of OKCs
to grow within the medullary bone, they have the
potential to become extremely large without causing
any clinical signs or symptoms.3,4 In the present case
there was no pain and discharge was present.
Radiographically, the OKC presents as a well-defined
radiolucency with thin corticated margins. The
majority of these are unilocular, but larger lesions
may be multilocular. Approximately 20-40 percent of
OKCs are associated with an unerupted tooth and can
be identical in appearance to a dentigerous cyst. Root
resorption is relatively uncommon.5 The present case
showed a well-defined radiolucency with thin
corticated margins and internal septae was present
giving it a multilocular appearance.
The histopathologic findings of the OKC are highly
specific. Diagnostic features include a uniform cyst
lining, hyperchromatic and palisaded basal cells,
wavy parakeratin production and a flat interface
between the epithelium and connective tissue wall
which was similar in the present case. Importantly,
these classic microscopic features are often
completely lost when the cyst is inflamed, presenting
an obvious diagnostic challenge which can lead to an
incorrect diagnosis.6
If multiple OKCs are present in a patient, a diagnosis
of nevoid basal cell carcinoma syndrome (NBCCS or
Gorlin syndrome) should be suspected. NBCCS is an
inherited genetic condition caused by mutation of the
PTCH1 gene.6 Other manifestations of the syndrome
include palmar and plantar pits, bifid ribs, calcified
falx cerebri and multiple basal cell carcinomas of the
skin. Unlike traditional basal cell carcinomas, the
lesions associated with NBCCS tend to be less
aggressive, hence the designation “nevoid,” or having
biologic behavior more similar to a nevus.6, 7
Differential diagnosis include dentigerous cyst (in
odontogenic keratocyst the cyst is connected to the
tooth at a point apical to cementoenamel junction),
ameloblastoma (usually multilocular, no straw
coloured fluid on aspiration), traumatic cyst
(unilocular with scalloped margins, rarely show
cortical expansion), giant cell granuloma (usually in
anterior region of jaw), odontogenic myxoma.5
Unlike most other odontogenic cysts, OKCs have a
striking tendency for recurrence (25-30 percent), with
Odontogenic keratocyst – a case report ________________________________________________________Garg S et al.
J Dent Specialities.2015;3(2):195-198 198
most recurrences developing during the first 5-7
years after therapy. Unfortunately, no practical
instruments or techniques are available to surgeons to
help predict which lesions will recur and which will
not. The recurrence of OKC, which is usual, is
thought to be based on great mitotic activity and
growth potential found in epithelium, furthermore
other sources of recurrences such as remnants of
dental lamina and epithelial islands have also been
proposed Suspected causes of recurrence are
incomplete removal of the original cyst lining,
growth of a new lesion from residual epithelial
islands or genotypic variations between lesions.8 For
these reasons, the treatment of OKCs continues to be
controversial. The challenge for the treating clinician
is to minimize both the risk of recurrence and patient
morbidity. Each case should be managed
individually, considering factors such as the age and
health of the patient, size of the lesion and risk of
damage to adjacent structures.5, 8
Marsupialization and decompression are conservative
therapies generally used for large lesions in order to
preserve bone, teeth and other vital structures, as well
as reducing the possibility of pathologic fracture.
They are particularly promising treatment modalities
for OKCs in children or patients who are poor
surgical candidates. Both procedures rely on the
principle of reducing the osmotic pressure of the cyst
by exposing it to the oral cavity. This results in bone
formation at the periphery of the lesion and a gradual
decrease in the size of the cyst. Marsupialization is a
one-step, definitive procedure in which the cyst
lining is directly sutured to the surrounding oral
mucosa, with eventual total resolution.3, 5
Decompression is a two-step procedure involving the
placement of a surgical drainage tube, followed by
enucleation at a later date once the cyst has shrunk to
a more manageable size. Exteriorization causes the
nature of the cyst lining to evolve into one that is
more similar to oral surface epithelium and therefore
easier to remove in one piece. Probably the greatest
disadvantage to marsupialization and decompression
is that they require extensive cooperation from the
patient and/or family members. The area must be
irrigated with saline and chlorhexidine daily, usually
for several months depending on the size of the
original cyst. The recurrence rate for marsupialized
lesions is approximately 40 percent.2, 5
Enucleation is the complete and intact removal of a
lesion by surgically husking it from the surrounding
tissues. Clinicians often report difficulty in
enucleating OKCs due to their thin, friable epithelial
lining and tendency to adhere to the surrounding
bone (or soft tissues in the case of cortical
perforation). Application of Carnoy’s solution is
another type of adjunctive therapy that destroys cyst
remnants by means of chemical cautery. Enucleation
combined with adjunctive treatment decreases the
potential for recurrence to 18 percent or less.7
Resection refers to the surgical removal of a section
of the involved jaw. Marginal resections leave behind
a rim of uninvolved bone, while a segmental
resection removes an entire portion of the jaw
without maintaining continuity.7,8
CONCLUSION
In conclusion, a biopsy specimen examination and
accurate clinical, radiographic, trans-surgical
observation along with follow up are essential to
avoid recurrence.
REFERENCES 1. Madras J, Lapointe H. Keratocystic Odontogenic
Tumour: Reclassification of the Odontogenic
Keratocyst from Cyst to Tumour. J Can Dent Assoc
2008;74:165-67.
2. Manor E, Kachko L, Puterman MB, Szabo G, Bodner
L. Cystic Lesions of the Jaws – A Clinicopathological
Study of 322 Cases and Review of the Literature. Int J
Med Sci. 2012;9:20-26.
3. Zecha JA, Mendes RA, Lindeboom VB, Van der wall
I. Recurrence rate of keratocystic odontogenic tumor
after conservative surgical treatment without
adjunctive therapies- A 35-year single institution
experience. Oral Oncol 2010;46:740-42.
4. Boffano P, Ruga E, Gallesio C. Keratocystic
odontogenic tumor (odontogenic keratocyst):
preliminary retrospective review of epidemiologic,
clinical, and radiologic features of 261 lesions from
University of Turin. J Oral Maxillofac Surg
2010;68:2994-99.
5. Bland PS, Shiloah J, Rosebush MS. Odontogenic
Keratocyst: A Case Report and Review of an Old
Lesion with New Classification. J Tenn Dent Assoc.
2012;92;37-38.
6. Morgan TA, Burton CC, Qian F. A retrospective
review of treatment of the odontogenic keratocyst. J
Oral Maxillofac Surg 2005;63:635-39.
7. Gomes CC, Diniz MG, Gomez RS. Review of the
molecular pathogenesis of the odontogenic keratocyst.
Oral Oncol 2009;45:1011-14.
8. Almeida P Jr, Cardoso Lde C, Garcia IR Jr, Magro-
Filho O, Luvizuto ER, Felipini RC. Conservative
approach to the treatment of keratocystic odontogenic
tumor. J Dent Child (Chic) 2010;77:135-39.
How to cite this article: Garg S, Sunil MK, Trivedi A, Singla N. Odontogenic keratocyst – a case report. J Dent Specialities,
2015;3(2):195-198.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest related to this study.
_________________________________________________________________________Case Report
J Dent Specialities.2015;3(2):199-201 199
Over denture using access post system: an alternative solution for
increasing retention
Vankadara SivaKumar1, R. B. Hallikerimath2, Ajinkya Patil3, Megha Sethi4
ABSTRACT One of the most common problems encountered by edentulous patients is lack of
retention and stability of prosthesis with decreased masticatory efficiency. An
overdenture treatment is one of the inevitable solutions for this condition. This case
report highlights the use of an “Access post over denture system” which is more
advantageous over the conventional tooth supported overdentures. The access post
overdenture fabricated was well retentive and esthetic serving as a
conservative approach to root preservation.
Keywords: Access post system, Complete denture, Overdenture, Ridge resorption,
Stud- attachment.
INTRODUCTION
n overdenture can be described as any
removable dental prosthesis that covers and
rests on one or more remaining natural teeth, the
roots of natural teeth, and/or dental implants.1 An
overdenture offers several advantages over
conventional dentures; to name the few are, retaining
the residual tooth structure while maintaining its
proprioception, preservation of the alveolar bone,
and additional support to the dentures apart from
the mucosa.2 Its acquisitions also include its
effectiveness and versatility in restoration and
improvisation of facial contour.3 Improvisation in the
retention in overdenture can be attained by using
various attachment systems which would ultimately
contrive in the patient’s acceptance.
CASE REPORT
A 64 year old male patient reported to the department
of prosthodontics, Maratha Mandal dental College,
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Belgaum with the chief complaint of missing teeth,
and in ability to chew food. On intra-oral
examination, it was found that that upper arch is
completely edentulous and partially edentulous lower
arch. Teeth found in the lower arch were 33, 43 (Fig.
1). Treatment plan was formulated as a conventional
denture in the maxillary arch and an access post
retained over denture with access posts in the 33, 43
teeth.
Scaling and root planning followed by intentional
root canal treatment of existing teeth no.33 & 43 was
done. Teeth no.33 & 43 were reduced in height to
a level just 1 mm above the marginal gingiva so as
to provide the necessary space for Access ball post.
The optimum sizes of the posts were selected by
placing them on the undistorted pre-operative IOPA
radiographs.
Once the appropriate size of the post was selected
post space was prepared in both the mandibular
canines using a sequence of Gates Gidden drills
followed by the colour coded primary reamer
supplied in the Essential Dental Systems Access post
overdenture kit which exactly correlates to post size
(Fig. 2). Following the radicular preparation in both
the mandibular canines the post space was irrigated
with saline to remove any debris and then dried up
using paper points. The access posts were placed in
the post space of both the mandibular canines to
check the initial fit and then verified by taking an
1Post Graduate student, 2Professor and Head, 3Post Graduate student,
Department of Prosthodontics and Crown
and Bridge, Maratha Mandal’s NG Halgekar Institute Dental Sciences and Research
Centre, Belgaum -590010, Karnataka -
INDIA. 4Senior Lecturer, ITS-Centre for Dental
Studies and Research, Delhi Meerut Road,
Murad Nagar, Ghaziabad (U.P.) –INDIA
Corresponding Author:
Dr. Vankadara SivaKumar Post Graduate student
Department of Prosthodontics and Crown
and Bridge, Maratha Mandal’s NG Halgekar Institute Dental Sciences and Research
Centre, Belgaum -590010, Karnataka -
INDIA. Email: [email protected]
Received: 28/07/2015 Accepted: 03/09/2015
A
Over denture using access post system: an alternative solution for increasing retention _____SivaKumar V et al.
J Dent Specialities.2015;3(2):199-201 200
IOPA radiograph and then, these posts were luted
with type-I Glass Inomer cement (Fig. 3).
Routine prosthodontic procedures involved in the
fabrication of complete dentures in both upper and
lower arches were carried out. These include alginate
impressions, border molding, final impressions with
addition silicone material followed by facebow
transfer and recording of jaw relations, try-in and
processing of the dentures (Fig.s 4,5).
Finally the chair side procedure was carried out to fit
the nylon caps in the intaglio surface of the lower
denture. The nylon caps with rubber bands were
placed on the male part of the posts (Fig. 6).
Markings were made on the intaglio surface of the
mandibular denture using a disclosing paste and the
area was trimmed and sufficiently relieved enough to
allow the denture to passively seat over the nylon
caps. A small amount of petroleum jelly was applied
on the marginal gingiva of the 33 and 43 regions.
These nylon caps were picked into the denture
directly in the patient’s mouth by placing a doughy
mixture of self-cure acrylic resin in to the relived
space. Patient was instructed to bite in centric
occlusion so as to keep it in position until the acrylic
is hardened (Fig. 7). Finally the excess amount of
acrylic was removed and the denture were finished
and polished. The post-operative results can be
appreciated in the Fig. 8.
Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Over denture using access post system: an alternative solution for increasing retention _____SivaKumar V et al.
J Dent Specialities.2015;3(2):199-201 201
Fig. 7
Fig. 8
DISCUSSION
Preventive prosthodontics lays emphasis on any
procedure which can delay or eliminate future
problems. The basic concept of an overdenture is the
preservation of hard and soft tissues in the oral
cavity.4,5 The phenomenon of residual ridge
resorption (RRR) following removal of teeth is well
observed and documented in the literature.6 It was
stated that the bone loss following removal of the
teeth is rapid, progressive, irreversible and inevitable.
While it was equally observed that it was well
maintained around standing teeth and implants.7 Bone
maintenance is the most significant advantage of a
tooth-borne overdenture, because of the maintenance
of the bone volume and vertical height which can
produce increased prosthetic retention and stability
while providing the patient with better comfort and
control over mastication due to proprioception.8 Over
denture attachments have demonstrated a significant
positive influence on retention, stability and tissue
response.9,10 Selection of an attachment is important
and it depends upon the available inter-arch space,
position of the abutments, and amount of retention
required, opposing dentition, clinical experience,
personal preference and cost.11 Access post over
denture system has a parallel sided passive post with
a thick walled hollow tube design. This design
provides the strength of a solid shank post and easy
retrievability to have an access to the apex of the root
in case on a failed root canal. Hollow tube design
allows venting of hydrostatic pressure during
cementation. It is basically a stud attachment which
occupies a small vertical space and doesn’t require
parallelism when placed in different roots, and also
allows the rotation of the denture. Standard nylon
caps provided with this system provides retention of
3-5 pounds and can be easily replaced at a low cost as
and when required8.
CONCLUSION
Inspite of many advances in dental implantology, the
conservative approach of root preservation is still
valid. Proper case selection and treatment planning is
of utmost importance in over denture therapy. However patient maintenance is also important part
of overdenture treatment to avoid failures resulting
from dental caries and periodontal diseases.
REFERENCES 1. Glossary of Prosthodontic Terms. J Prosthet Dent.
2005;94.
2. DeFranco LR. Overdentures. In, Winkler S (ed),
Essential of complete denture prosthodontics, 2nd ed.
USA, Inc Publishers, 2004; 384-02.
3. Brewer AA, Morrow RM. Overdentures. 2nd ed. St
Louis: CV Mosby; 1980.
4. Winkler .S. Essentials of complete denture
Prosthodontics, 2nd ed. 2000:384-02.
5. Kalpana C, Prasad KV. Seeing The Unseen :
Preventive Prosthodontics : Use Of Overlay
Removable Dental Prosthesis. Annals and Essences of
Dent. 2010;2:44-9.
6. Toolson LB, Smith DE. A two year longitudinal study
of overdenture patients, Part 1: Incidence and control
of caries on overdenture abutments. J Prosthet Dent.
1978;40:486-91.
7. Tallgren A. The continuing reduction of the residual
alveolar rides in complete denture wearers: a mixed
longitudinal study covering 25 years. J Prosthet Dent.
1972;27:120-32.
8. Jain DC, Hegde V, Aparna I, Dhanasekar B.
Overdenture with access post system: A clinical report.
Indian J Dent Res. 2011;22:359-62.
9. Burns DR, Unger JW, Elswick RK, Giglio JA.
Prospective clinical evaluation of mandibular implant
overdentures part II: patient satisfaction and
preference. J. Prosth. Dent. 1995;73:364-70.
10. Naert I, Quirynen M, Hooghe M, Van Steenberghe D.
A comparative prospective study of splinted and
unsplinted Branemark implants in mandibular
overdenture therapy: a preliminary report. J Prosth
Dent. 1994;71:786-92.
11. Schwartz IS, Morrow RM. Overdentures. Principles
and procedures. Dent Clin North Am. 1996;40:169-94.
How to cite this article: SivaKumar V, Hallikerimath RB, Patil A,
Sethi M. Over denture using access post system: an alternative solution for increasing retention. J Dent Specialities,
2015;3(2):199-201.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest related to this study.
_________________________________________________________________________Case Report
J Dent Specialities.2015;3(2):202-206 202
Total mandibulectomy in a patient with verrucous carcinoma turning
into squamous cell carcinoma of the oral cavity: a rare case report Chandrashekhar R. Bande1, Dinesh Mohale2, Manjiri Thakur3, Pravin Lambade4
ABSTRACT Verrucous Carcinoma is a rare type of low grade, well differentiated squamous cell
carcinoma. The author herein reports a case of squamous cell carcinoma arising within
verrucous carcinoma of mandible. A 65-year old women reported to hospital with the
history of swelling over the gums of lower jaw since 1yr. Her swelling was painless and
gradually had spread to the whole mandible. Incisional biopsy and histopathologic
examination revealed verrucous carcinoma which was treated with total Mandibulectomy.
Keywords: Verrucous Carcinoma, Total Mandibulectomy, Squamous Cell Carcinoma
INTRODUCTION
ral Verrucous Carcinoma is characterized by
predominantly Exophytic overgrowth of well
differentiated keratinizing epithelium having minimal
atypia and with locally destructive pushing margins
at its interface with underlyling connective tissue. It
is distinct in its slow growth and ability to become
locally aggressive if not treated appropriately.
However, even with local tumors progression, it is
intriguing that regional or distant metastasis is rare.
Oral Verrucous Carcinoma has unique histopatho-
logical features.1
An accurate pathological diagnosis is challenging and
is facilitated by an adequate tumor sample for study
and more importantly, a close collaboration between
the clinician and the pathologist. The 19th and 20th
century reflect the development of head and neck
oncology in the era of science based medicine.
Almost all of our current understanding of head and
neck oncology, our diagnostic methods and treatment
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strategies have been developed in these two
centuries.2
The prognosis of verrucous carcinoma is generally
good since nodal metastases does not occur.
However, in 20% of cases, verrucous carcinoma co-
exists with conventional squamous cell carcinoma
with a consequent reduced prognosis.3
We report a case of squamous cell carcinoma arising
within oral verrucous carcinoma of mandible which
was treated with total Mandibulectomy and
reconstruction of a total mandibular defect that
involved the entire mandible.
CASE REPORT
A 65 year old female patient (Fig.1) reported to the
hospital with a history of swelling since 6-8 months,
the lesion was extended from left premolar area to
right premolar area (Fig.2). Patient was not ready for
treatment. She was taking ayurvedic medicine for 6
months .Patient however reported 6 months later with
swelling involving entire mandible including condyle
bilaterally and with pathological fracture at right side
of condylar neck (Fig.3). Submandibular and
submental Lymph nodes were enlarged and tender on
palpation.
Incisional Biopsy was taken. The general
histopathological characteristics of the specimens
revealed acanthosis, hyperkeratosis of the epithelium
with keratin plugging. There was minimal atypia or
1Associate Professor, 4Professor &
Head, Dept.of Oral and Maxillofacial Surgery, 2Post Graduate student, 3Professor &
HOD, Dept. Oral & Maxillofacial pathology and Microbiology,
Swargiya Dadasaheb Kalmegh Smruti
Dental College & Hospital,
Waddhamana road, Wanadongari,
Hingna, Nagpur-440010, Maharashtra,
India
Address for Correspondence:
Dr. Chandrashekhar R. Bande Dept. Oral & Maxillofacial pathology
and Microbiology,
Swargiya Dadasaheb Kalmegh Smruti Dental College & Hospital,
Waddhamana road, Wanadongari,
Hingna, Nagpur-440010, Maharashtra, India
Email: [email protected] Received: 08/04/2015
Accepted: 05/07/2015
O
Total mandibulectomy in a patient with verrucous carcinoma turning into squamous cell carcinoma of the oral cavity: a rare case report __________________________________________Bande CR et al.
J Dent Specialities.2015;3(2):202-206 203
mitotic activity. Verrucous carcinoma was diagnosed
following histopathological examination.
For definitive diagnosis, the entire masses with their
surrounding tissues had to be excised. Operative
procedure was planned under general anaesthesia
with nasal intubation. Bilateral Apron flap was taken
with midline split from left corner of mouth, layer by
layer dissection was done.
The supra-omohyoid neck dissection-The skin flap
was raised in sub platysmal layer up to inferior
border of the mandible anteriorly and to tip of
mastoid process posteriorly. The inferior flap was
also raised taking care of anterior jugular vein. The
venous perforators going to platysma were
cauterized, the lower level of dissection ended
inferior to the intersection of sternocliedomastoid and
superior belly of omohyoid muscle. The posterior
border of the sternocliedomastoid was dissected free
from adjoining fibrofatty tissue. The external jugular
vein was ligated. The spinal accessory nerve, anterior
border of sternocliedomastoid was dissected till its
exposed entire length. The sternocliedomastoid was
separated from all the attachments. The
sternocleidomastoid was skeletelised and retracted
posteriorly. The carotid sheath was opened, middle
thyroid and common facial veins were ligated. After
the entire fibrofatty tissue was separated along with
the embedded lymph nodes, the superior belly of
omohyoid was defined. The fibro fatty tissue and
lymph nodes between omohyoid and anterior aspect
of internal jugular vein were mobilized enblock from
base of carotid triangle to the level of digastric
muscle. Then, the dissection was carried in the
posterior triangle. The skeletalised spinal accessory
nerve, internal jugular vein common carotid artery
was retracted. The cutaneous branch of c3and c4
roots were lifted block and were divided. The spinal
accessory nerve up to sternocliedomastoid and the
fibro-fatty tissue around were dissected. The
dissection then goes superiorly to parotid gland
which was palpated and lifted carefully and the
lymph nodes were excised. The dissection was then
carried anteriorly and the retromandibular vein was
ligated. Tumor mass was defined first on right side
from midline to condyle and sparing all the muscles
of speech and mastication on buccal as well as
lingual side. Same way dissection was carried out in
the left side from midline to condyle. After the
excision of the specimen, the margins were found
clear. In the neck submandibular and submental
nodes were hypertrophic, and were excised
separately.
Disarticulation of mandible was done first on the left
side with thorough separation of tumor from the
normal tissue, disarticulation of right condyle was
also done in same fashion. In this way total mandible
was resected (Fig.4).
The complete mandibular reconstruction plate
prosthesis (Fig.5) which was planned by using the
patient’s x-rays was used for reconstruction purpose.
However, minor adjustments were still required to
place the prosthesis in harmony with maxilla.
All muscles of mastication and the tongue were
sutured back to the reconstruction plate in place
(Fig.6). Three layer closure was done from intraoral
to extraoral site with placement of bilateral suction
drain. (Fig.7)
Post resection specimen was sent for
histopathological evaluation and the details of which
are as follows:
Histopathological report: (Fig 8 a,b,c)
The section shows hyperplastic stratified squamous
epithelium showing mild to moderate dysplasia.
There is hyperparakeratinization with formation of
keratin plugging. Rete ridges are bulbous invading
deep into connective tissue. Pattern of invasion is of
pushing type. Connective tissue is infiltrated with
sheets of squamous epithelial cells with lots of
keratin formation. Little nuclear pleomorphism is
seen. Number of mitosis seen is 0-1 per high power
field. There is scanty connective tissue with moderate
amount of chronic inflammatory cell infiltration.
Bony flakes are present at some places.
Histopathology of lymph node shows normal
architecture. Lymph nodes are negative for
metastasis.
Diagnosis: Well-differentiated squamous cell
carcinoma. (Bryne’s grade I type).8
Postoperative course was uneventful and patient was
disease free even after six month follow up period.
(Fig: 9 a, b)
Fig. 1: Preoperative extraoral view of patient
Total mandibulectomy in a patient with verrucous carcinoma turning into squamous cell carcinoma of the oral cavity: a rare case report __________________________________________Bande CR et al.
J Dent Specialities.2015;3(2):202-206 204
Fig. 2: Preoperative intraoral view
Fig. 3: Radiograph reveals a lytic lesion in the
mandible extending bilaterally towards condyles
Fig. 4: Showing Resected Mandible
Fig. 5: Mandibular reconstruction plate
Fig. 6: Reconstruction plate in position
Fig. 7: Flaps sutured and placement of drains
Total mandibulectomy in a patient with verrucous carcinoma turning into squamous cell carcinoma of the oral cavity: a rare case report __________________________________________Bande CR et al.
J Dent Specialities.2015;3(2):202-206 205
Fig. 8 (a): Photomicrograph showing Islands of
epithelial cells with parakeratin pluggings. (H and
E, 10x)
Fig. 8 (b): Photomicrograph showing epithelial
cells with mild dysplasia (H and E, 10x)
Fig. 8 (c): Photomicrograph of lymph node
showing normal architecture (H and E, 4x)
Fig. 9: Postoperative patient view after 6 months
DISCUSSION
The etiopathogenesis of Oral Verrucous Carcinoma is
unclear, however, studies have shown strong
associations with tobacco use, including inhaled as
well as smokeless tobacco, alcohol, and opportunist
viral activity associated with human papilloma virus
(HPV). More recently, studies have further confirmed
the association between HPV and Verrucous
Carcinoma by detecting HPV–DNA types 6, 11, 16,
and 18 by polymerase chain reaction (PCR),
restriction fragment analysis, and DNA slot–blot
hybridization. Surgical excision with adequate
margins of resection seems to be the clear preference
for treatment.
Verrucous carcinoma tends to destroy bony structures
such as the mandible, on a broad front, eroding with a
sharp margin rather than infiltrating the marrow
spaces.1 In our case there was associated pathological
fracture of right condylar neck of mandible. The
prognosis of verrucous carcinoma is generally good
since nodal metastases do not occur. However, in
20% of cases, verrucous carcinoma co-exists with
conventional squamous cell carcinoma with a
consequent reduced prognosis.
Preoperative diagnosis of mandibular invasion by
squamous carcinoma is not accurate for early lesions.
A combination of clinical examination, plain
radiographs, and CT imaging will provide the most
information. Among patients treated with some form
of mandibular resection because of suspected
Squamous Cell Carcinoma invasion (excluding cases
of clear gross involvement), less than half (39% to
45%) are proved to have histologic invasion of the
cortex. Therefore, conservative mandibular surgery
will not jeopardize complete tumor excision for most
patients with “suspected” but not proven carcinoma
in the mandible.4 Buccal squamous cell carcinoma
has traditionally been treated surgically, with
postoperative radiation therapy reserved for patients
with high-risk histopathologic findings, such as
perineural invasion, lymphovascular invasion, bone
invasion, extracapsular spread, or close margins.5
Total mandibulectomy in a patient with verrucous carcinoma turning into squamous cell carcinoma of the oral cavity: a rare case report __________________________________________Bande CR et al.
J Dent Specialities.2015;3(2):202-206 206
Reconstructive options includes Vascularized
osseous free tissue transfer for mandibular
reconstruction. The long-term excellent functional
and aesthetic outcomes of this technique have
recently been reported. The most commonly used
osseous free flaps for mandibular reconstruction are
the fibula, iliac crest, and scapula. Each of these
typically accepts endosseous implants improving
functional outcomes. The use of mandibular
reconstruction plates and coverage with a soft-tissue
flap is a reconstructive option for selected patients.
The latest refinements in technique include
temporary intraoperative external fixation, the use of
periosteal free flaps and development of
biodegradable biopolymer scaffolds for mandibular
defects.
In our reported case, the whole mandible along with
both condyles was removed. As verrucous carcinoma
demonstrated transformation of the lesion in to
squamous cell carcinoma in depth of resected
mandible. Loss of mandibular continuity results in
alteration in speech, swallowing and mastication, and
in the appearance of the patient. The restoration of a
defect that involves the entire mandible is a rare and
challenging problem for surgeons after ablation of
malignant and aggressive tumors.6 The purpose of
reconstruction is mainly to rehabilitate the patient
esthetically by improving the contour of the
mandible, thereby minimizing facial deformity from
the defect. The patient is rehabilitated functionally
and the occlusal disturbance is minimized.7
CONCLUSION
It is mandatory to rule out hybrid carcinoma
including Verrucous Carcinoma and conventional
squamous cell carcinoma. But, in any scenario,
timely and correct diagnosis of the lesion and
appropriate surgical management is of extreme
importance to minimize postoperative morbidity and
to improve quality of life of the patient.
REFERENCES: 1. Rohan RW, Devendra A, Chaukar A, Mandar S.
Verrucous carcinoma of the oral cavity: A clinical and
pathological study of 101 cases. Oral Oncology.
2009;45:47– 51.
2. Benedikt JF, Carl ES, Alessandra R, Johannes J. An
outline of the history of head and neck oncology. Oral
Oncology. 2008;44: 2–9.
3. Julia AW. Histopathological prognosticators in oral
and oropharyngeal squamous cell carcinoma. Oral
Oncology. 2006;42:229–39.
4. Robert AO, Majgan S. A Comparison of Segmental
and Marginal Bony Resection for Oral Squamous Cell
Carcinoma Involving the Mandible. J Oral Maxillofac
Surg. 1997;55:470-77.
5. Adam DC, Mia EM, Beth P, Chi L. Squamous cell
carcinoma of buccal mucosa: a 40-year review. Am J
Otolaryngology–Head and Neck Medicine and Surg.
2012;33:673–77.
6. Jelena VJ, Zivorad SN, Ivan VB. Total mandibular
reconstruction after resection of rare ‘‘honeycomb-
like’’ ameloblastic carcinoma - A case report. J
Cranio-Maxillo-Facial Surg. 2010;38:465-68.
7. Mobolanle OO, Jelili AA, Akinola LL, Wasiu LA.
Spontaneous Regeneration of Whole Mandible after
Total Mandibulectomy in a Sickle Cell Patient. J Oral
Maxillofac Surg. 2006;64:981-84.
8. Kurokawa H, Zhang M, Matsumoto S, Yamashita Y.
The high prognostic value of the histologic grade at the
deep invasive front of tongue squamous cell
carcinoma. J Oral Pathol Med. 2005;34:329–33. How to cite this article: Bande CR, Mohale D, Thakur M,
Lambade P. Total mandibulectomy in a patient with verrucous carcinoma turning into squamous cell carcinoma of the oral cavity:
a rare case report. J Dent Specialities,2015;3(2):202-206.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest related to this study.
_________________________________________________________________________Case Report
J Dent Specialities.2015;3(2):207-210 207
Platelet rich fibrin: a panacea for lost interdental papilla
Shivanand Aspalli1, Nagappa G2, Aditi S. Jain3
ABSTRACT Introduction: Loss of interdental papilla marks phonetics, functional and esthetic
problem. Surgical techniques are diverse, but none have given predictable results.
Aim: The purpose of this case report is to present reconstruction of papilla by using
platelet rich fibrin membrane in maxillary anterior region.
Methodology: 30yr old male patient reported with an unesthetic smile due to loss of
interdental papilla in the maxillary left central and lateral incisor region since 6 months.
The treatment was planned for reconstruction of lost interdental papilla using PRF. A
pouch was created with a semilunar incision, PRF was prepared and inserted into the
pouch and the entire gingivopapillary unit was displaced coronally.
Conclusion: Optimal fill was noted at 1, 3 and 6 months postoperatively with excellent
esthetic outcome. Use of PRF and proper technique may thus be the panacea for
interdental papilla augmentation.
Keywords: PRF, Interdental papilla, Esthetics, Maxillary anterior, Black triangle
INTRODUCTION rom the time known, dentistry has just been a
restricted field but now dentistry has expanded its
horizons. Today as we head towards modernization
and urbanization esthetic demands in dentistry have
increased rapidly, driven by an enhanced awareness
of beauty and esthetics. The ultimate goal in modern
dentistry is to achieve “white” and “pink” esthetics.
“White esthetics” are the natural dentition or the
restoration of dental hard tissues with suitable
materials. “Pink esthetics” refers to the surrounding
hard and soft tissues, which can enhance or diminish
the esthetic result.
Today, in majority of the adult population with a
history of periodontal disease, open gingival
embrasures are a common problem resulting in
“black triangles”. A black triangle or an open
gingival embrasure occurs as a result of a deficiency
or loss of papilla beneath the contact point.
Periodontists have attempted to reconstruct this lost
papilla by numerous surgical methods like free
gingival grafting, coronally positioning of the papilla
from the palatal side, subepithelial connective tissue
graft with apically positioning of the papilla.
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DOI: 10.5958/2393-9834.2015.00017.0
A recent innovation in dentistry is the preparation
and use of platelet-rich fibrin (PRF), a concentrated
suspension of the growth factors found in platelets
derived from centrifuged blood. Platelet rich fibrin
(PRF) is a type of platelet gel; a matrix of autologous
fibrin, which has scored over platelet rich plasma by
virtue of its properties, easier preparation, and cost
effectiveness. It promotes wound healing, wound
sealing and hemostasis.1 The purpose of this case
report is to present the use of platelet rich fibrin
(PRF) in the reconstruction of papilla in the maxillary
anterior region of a 30 years old man.
CASE REPORT
A 30 year old male patient reported to the
Department of Periodontics, A.M.E’s dental college
& hospital with a chief complaint of gap and black
appearance in upper front teeth. On Clinical
examination it was observed that class 1 papillary
loss (Fig. 1). The distance between the contact point
to the bone crest was 6 mm. No facial recession was
evident on 11, 12, and 21. The distance between the
contact point of adjacent teeth and the existing
papilla was 4 mm. The surgical procedure was
explained and informed consent was obtained.
Preparation of PRF: Before the start of the surgery
the preparation of PRF was carried out as per the
protocol developed by Choukron et al. en milliliter of
intravenous blood (antecubital site) was collected in
sterile 10 ml tubes without the addition of an
anticoagulant and centrifuged at 3000 revolutions
(≈400 × g) per minute for 10 minutes. PRF settles
down between the platelet poor plasma (PPP) at the
top and the red blood cells (RBC) at the bottom of the
1Prof. & Head of the Department, 2Reader, 3Post graduate Student, Department of Periodontics & Oral
Implantpology, A.M.E’s Dental College
& Hospital, Bijangera road, Raichur - 584103 Address for Correspondence Dr. Aditi S. Jain
Post graduate Student
Department of Periodontics & Oral
Implantpology, A.M.E’s Dental College
& Hospital, Bijangera road,
Raichur – 584103
Email: [email protected]
Received: 24/08/2015
Accepted: 20/10/2015
F
Platelet rich fibrin: a panacea for lost interdental papilla _____________________________________Aspalli S et al.
J Dent Specialities.2015;3(2):207-210 208
tube. Platelet rich fibrin at the center with platelet
poor plasma at the top and red blood cells at the
bottom of the test tube.2
SURGICAL PROCEDURE
Intraoral antisepsis was performed by rinsing with
0.2% chlorhexidine digluconate for 30 seconds.
Adequate local anesthesia was achieved with 2%
lignocaine hydrochloride (HCL). A split thickness
semilunar incision was given about 1 mm coronal to
the mucogingival junction in the interdental region of
21,22(Fig. 2).3 Through the semilunar incision
towards the interdental papillae, the split thickness
flap was continued to create a pouch in the
interdental area (Fig. 2). The prepared PRF was
removed using sterile tweezers and trimmed with
scissors and transferred on to sterile gauze (Fig. 3). A
thick fibrin membrane was obtained by squeezing the
serum out of the PRF clot. A curette was used around
the necks of 21 and 22 to free the tissue attachment
from the root surface, facilitating the displacement of
gingivopa-pillary unit coronally.4 This membrane
was eased in to the pouch and pushed coronally,
enabling to fill the bulk of the interdental papillae
(Fig. 4). The incisions were secured with 4-0 non-
resorbable sutures (Fig. 5). The surgical area was
protected with a light cured periodontal dressing.
Analgesics were prescribed along with chlorhexidine
digluconate (0.2%) rinse twice daily for 10 days.
Patient was abstained from brushing at the surgical
area and was asked to clean the tooth surface with the
cotton pellet dipped in the 0.2% chlorhexidine
mouthwash for 10 days. Postoperative healing was
uneventful with minimal pain. Review of the patient
on 10th day revealed partial fill of the interdental
region. The patient was then evaluated for 1 month, 3
months & 6 months (Fig. 6).
Fig. 1: pre-operative picture of lost interdental
papilla irt 21 and 22
Fig. 2: Semilunar incision taken 1 mm coronal to
mucogongival junction & pouch created through
the semilunar incision
Fig. 3: Prepared PRF
Fig. 4: coronally displaced pouch with PRF
Platelet rich fibrin: a panacea for lost interdental papilla _____________________________________Aspalli S et al.
J Dent Specialities.2015;3(2):207-210 209
Fig. 5: sutures placed
Fig. 6: post- operative view after 6 months
DISCUSSION
The loss of gingival embrasures occurs due to several
factors including periodontal disease, length of
embrasure area, root angulations, interproximal
contact position, changes in papilla during
orthodontic alignment and triangular-shaped crowns.
Also deficiency of the papillae might be a
consequence of post periodontal surgery.
An assortment of surgical procedures has been tried
out in papilla reconstruction. Shapiro et al. advocated
use of repeated curettage to stimulate the regrowth of
interdental papillae in necrotizing ulcerative
gingivitis.5 The roll technique and the use of pedicle
graft with coronal displacement of the
gingivopapillary unit and subepithelial connective
tissue grafting has been presented.6,7 Interpositional
subepithelial connective tissue grafting and use of
buccal and palatal split thickness have been tried
out.8 Interdental papilla augmentation along with
reconstruction of interdental bone to create
appropriate support for gingival papilla has been
reported.9
This technique using PRF flap offers a reliable
solution as PRF membrane has both mechanical
adhesive properties and biologic functions like fibrin
glue; it maintains the flap in stable position, enhances
neoangiogenesis, reduces the necrosis and shrinkage
of the flap and stabilization of the gingival flap in the
highest covering position.10 The PRF is easy to
procure, not expensive and can be prepared in few
minutes. PRF provides ideal healing properties. This
fibrin matrix inclusive of its platelets, leucocytes, and
cytokines allow remodeling of interdental papilla to
occur. It has been found PRF organized as a dense
fibrin scaffold with a specific release of growth
factors (TGF-1β, PDGF-AB, and vascular endothelial
growth factor (VEGF) and glycoproteins
(thrombospondin -1) during ≥ 7 days, is critical for
the “take” of the grafted PRF membrane.11
Platelet cytokines, platelet derived growth factors
(PDGF)-α and (PDGF)-β, transforming growth factor
beta (TGF)-β and insulin-like growth factor-1 (IGF-
1) are gradually released, aiding the process of
healing. Advantages of using PRF is that the need for
donor site is eliminated, making the technique less
invasive, lessens postsurgical discomfort, promotes
rapid soft tissue healing with less edema compared to
connective tissue graft and enamel matrix derivative
technique. Thus, it is easy to prepare and lacks
biochemical handling of blood, which makes this
preparation strictly autologous.
CONCLUSION
The reconstructed papilla was examined at 1, 3 & 6
months post-operatively (Fig.8,9,10). Clinically it
shows the coverage of the defect (Fig. 11,12). By this
it can be concluded that this technique improves the
esthetics of the patient and it is one of the simple and
easy procedure for the reconstruction of the lost
papilla. However, studies with a longer duration are
required to determine the success rate and
predictability of this procedure.
REFERENCES 1. Simonpieri A, Del Corso M, Sammartino G, Dohan
Ehrenfest DM. The relevance of Choukroun’s
platelet‑rich fibrin and metronidazole during complex
maxillary rehabilitations using bone allograft. Part I: A
new grafting protocol. Implant Dent 2009;18:102-11.
2. Sunitha Raja V, Munirathnam Naidu E. Platelet-rich
fibrin: Evolution of a second generation platelet
concentrate. Indian J dent Res 2008;19:42-6.
3. Han TJ, Takkei HH. Progress in gingival
reconstruction. Perio 1996;11:65-8.
4. Azzi R, Etienne D, Carranza F. Surgical reconstruction
of the interdental papilla. Int J Periodontics Restorative
Dent 1998;18:466-73.
5. Shapiro A. Regeneration of interdental papillae using
periodic curettage. Int J Periodontics Restorative Dent
1985;5:26-33.
6. Beagle JR. Surgical reconstruction of the interdental
papilla: Case report. Int J Periodontics Restorative
Dent 1992;12:145-51.
Platelet rich fibrin: a panacea for lost interdental papilla _____________________________________Aspalli S et al.
J Dent Specialities.2015;3(2):207-210 210
7. Han TJ, Takei HH. Progress in gingival papilla
reconstruction. Periodontol 1996;11:65-8.
8. Azzi R, Etienne D, Carranza F. Surgical reconstruction
of the interdental papilla. Int J Periodontics Restorative
Dent 1998;18:466-73.
9. Azzi R, Takei HH, Etienne D, Carranza FA. Root
coverage and papilla reconstruction using autogenous
osseous and connective tissue grafts. Int J Periodontics
Restorative Dent 2001;21:141-47.
10. Del Corso M, Sammartino G, Dohan Ehrenfest DM.
Re: Clinical evaluation of a modified coronally
advanced flap alone or in combination with a
platelet‑rich fibrin membrane for the treatment of
adjacent multiple gingival recessions: A 6-month
study. J Periodontol 2009;80:1697-99.
11. Dohan Ehrenfest DM, de Peppo GM, Doglioli P,
Sammartino G. Slow release of growth factors and
thrombospondin‑1 in Choukroun’s platelet‑rich fibrin:
A gold standard to achieve for all surgical platelet
concentrates technologies. Growth Factors 2009;27:63-69.
How to cite this article: Aspalli S, Nagappa G, Jain AS. Platelet
rich fibrin: a panacea for lost interdental papilla. J Dent
Specialities, 2015;3(3):1-3.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
_________________________________________________________________________Case Report
J Dent Specialities.2015;3(2):211-216 211
Creating smiles- the holistic way!! – orthodontic- surgical correction of
bimaxillary protrusion
Ashutosh Shetty1, Priyanka Basu2, Vivek Bhaskar3, U.S. Krishna Nayak4
ABSTRACT Often many patients cannot be treated by orthodontics alone, and need the combined
efforts of orthodontics and orthognathic surgery. Such patients are treated in three phases-
a phase of pre surgical orthodontics that involves basically decompensating the dentition,
followed by the surgery, which is then finished with final detailing of the occlusion. This
article is a case report of a skeletal bimaxillary protrusion patient, who was treated with
bi- jaw surgery.
Keywords: Surgical Orthodontics, Bimaxillary protrusion, Bijaw surgery, Prosthetic
rehabilitation.
INTRODUCTION
t has been estimated that the want towards facial
normalcy is one of the main reasons patients ask
for orthodontic treatment, which causes profound
psycho social effects.1 But often, it is found that just
orthodontic treatment does not suffice to reach the
optimum soft tissue goals for a patient, and that the
aid of orthognathic surgery has to be taken. The
dentition has been shown to compensate, so to speak,
for the underlying skeletal malformation, which has
to be decompensated before any sort of surgical
alteration can be thought of following adequate
decompensation, surgery is carried out, following
which final finishing and detailing of the occlusion is
done.2
Also, as in this case, many cases present to the
orthodontist with compromised dentition, and
appropriate prosthetic replacement has to be planned
beforehand, keeping in mind the molar and canine
relations, and ideal smile esthetics.3
CASE REPORT
A 22 year old male patient reported to us with a chief
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complaint of forwardly placed upper front teeth. He
had no significant medical history. He gave a history
of extraction of a carious upper left pre molar.
On extra oral examination, he was seen to be
brachycephalic, leptoproscopic with a convex profile,
consciously competent lips, and a vertical growth
pattern. (Fig 1 to 3)
On intra oral examination, he presented with a Class I
canine and molar relationship bilaterally, missing 24,
anterior open bite of 6mm and an overjet of 7mm.
(Fig 4 to 8)
The pre- treatment lateral cephalogram (Fig 9)
revealed a reduced nasolabial angle, retrognathic
mandible, proclined upper and lower anteriors, and a
vertical growth pattern (Table 1)
Using the above diagnostic information, the diagnosis
was arrived to be Class II skeletal base with vertical
growth pattern, anterior open bite with proclination,
and protrusive lips.
The treatment plan was decided to be a non-
extraction orthodontic- orthognathic surgical one.
This included:
Pre surgical orthodontics:
Non extraction Leveling and aligning
Surgical Plan:
LeFort I Osteotomy with differential
impaction.
Mandibular advancement rotation
(anticlockwise).
Advancement genioplasty.
1Professor, 2Ex Post Graduate Student,
3Post Graduate Student, 4Principal and Dean, Head of Department,
Department of Orthodontics and
Dentofacial Orthopaedics,
A.B. Shetty Memorial Institute of
Dental Sciences,
Mangalore
Address for Correspondence:
Dr. Vivek Bhaskar Post Graduate Student, Department of
Orthodontics and
DentofacialOrthopaedics, A.B. Shetty Memorial Institute of Dental Sciences,
Mangalore
Email: [email protected]
Received: 24-10-2014
Accepted: 26-03-2015
I
Creating smiles- the holistic way!! – orthodontic- surgical correction of bimaxillary protrusion ___Shetty A et al.
J Dent Specialities.2015;3(2):211-216 212
Post Surgical Orthodontics
Settling of occlusion
The presurgical phase started with bonding of MBT
0.022” prescription brackets. Initial levelling and
aligning was achieved with sequential Ni Ti wires,
till the final working wire of 19x 25 S.S was in place.
This phase lasted for 8 months, following which the
patient was posted for surgery. (Fig 10,11,12)
The surgeries done were LeFort I Osteotomy with
differential impaction, Mandibular advancement
rotation (anticlockwise) and Advancement
genioplasty. The surgical phase involved
overcorrection of the malocclusion into a class III
pattern. Due to the mandibular anti clockwise
rotation there was an apparent uprightening of the
lower incisors. Also in case of maxilla due to
differential impaction there was a decrease in SNA
angle and an apparent increase in the maxillary
anterior proclination. Following surgery, the patient
was put on intermaxillary fixation for a period of 2
weeks. After this, settling elastics were prescribed for
a month. Post debond, the patient was referred to the
Department of Prosthodontics for replacement of the
missing 24. The patient was put on clear
thermoformed retainers immediately after debond, as
well as, a new set after the prosthesis delivery, for a
period of 12 months.
The entire treatment from pre surgical orthodontics to
post debond prosthetic replacement lasted for a
period of 17 months. The self- confidence and self-
perception of the patient improved considerably, and
the decided treatment plan resulted in satisfactory
facial balance and esthetics, coupled with excellent
occlusion. (Fig 13 to 20)
The post treatment cephalogram (Fig 21) (Table 1)
showed drastic changes in the maxillary prognathism,
lip balance, and incisor proclination, indicative of a
successful treatment.
Table: 1
Cephalometric Values Pre
Treatment
Post
Debond
SNA 830 760
SNB 760 790
WITS 5mm 2.5mm
N-A-Pg 160 -90
Upper Incisor to NA 23 0 / 6mm 360/17mm
Lower Incisor to NB 45o / 19mm 38o / 15mm
Lower incisor to Mand.
plane
110o 90o
Inter-incisal Angle 105o 109o
Nasolabial Angle 97o 105o
Upper lip to E line 6mm -3mm
Lower lip to E line 12mm -2mm
Upper lip to S line 9mm 1mm
Lower lip to Sline 15mm 3mm
Fig. 1: Pre Treatment Extra Oral Images
Fig. 2: Pre Treatment Extra Oral Images
Creating smiles- the holistic way!! – orthodontic- surgical correction of bimaxillary protrusion ___Shetty A et al.
J Dent Specialities.2015;3(2):211-216 213
Fig. 3: Pre Treatment Extra Oral Images
Fig. 4: Pre Treatment Intra Oral Images
Fig. 5: Pre Treatment Intra Oral Images
Fig. 6: Pre Treatment Intra Oral Images
Fig. 7: Pre Treatment Intra Oral Images
Fig. 8: Pre Treatment Intra Oral Images
Fig. 9: Pre Treatment Lateral Cephalogram
Creating smiles- the holistic way!! – orthodontic- surgical correction of bimaxillary protrusion ___Shetty A et al.
J Dent Specialities.2015;3(2):211-216 214
Fig. 10: Pre Surgical Images
Fig. 11: Pre Surgical Images
Fig. 12: Pre Surgical Images
Fig. 13: Post Treatment Intra Oral Images
Fig. 14: Post Treatment Intra Oral Images
Fig. 15: Post Treatment Intra Oral Images
Fig. 16: Post Treatment Intra Oral Images
Fig. 17: Post Treatment Intra Oral Images
Creating smiles- the holistic way!! – orthodontic- surgical correction of bimaxillary protrusion ___Shetty A et al.
J Dent Specialities.2015;3(2):211-216 215
Fig. 19: Post Treatment Extra Oral Images
Fig. 20: Post Treatment Extra Oral Images
Fig. 21: Post Treatment Extra Oral Images
Fig. 22: Post Treatmen Cephalogram
Creating smiles- the holistic way!! – orthodontic- surgical correction of bimaxillary protrusion ___Shetty A et al.
J Dent Specialities.2015;3(2):211-216 216
DISCUSSION
Taking into consideration the cephalometric
variables, coupled with the clinical examination, it
was clearly evident that the patient needed a surgical
intervention to address his chief complaint. This
particular patient was ready for surgery, but if not for
surgery camouflage alternatives would have to be
considering it as a bimaxillary protrusion case and
treat with extraction of pre molars and intrusion of
the maxillary posteriors, with accompanying auto
rotation of the mandible. However, this would lead to
compromised esthetics, and highly prone to relapse.4,5
As far as retention protocol was concerned, we felt
that the best method would be one that covers the
entire dentition, giving retention to all the teeth, and
hence we gave the patient clear thermoformed
retainers.6
CONCLUSION
In this case, i.e a bimaxillary protrusion, adequate
non extraction pre surgical orthodontics, followed by
bijaw surgery gave satisfactory results.
The change in the patient’s self-esteem and self-
image drastically improved, indicating the
psychosocial impact of Orthodontic- Orthognathic
Surgery.
REFERENCES 1. D Roberts-Harry, J Sandy. Orthodontics. Part 1: Who
needs orthodontics? British Dental Journal 2003;195,
433.
2. Anwar N, Fida M. Evaluation of dentoalveolar
compensation in skeletal class II malocclusion in a
Pakistani University Hospital setting. J Coll Physicians
Surg Pak. 2009;19:11-6
3. K. S. Senthil Kumar, Deepika, Triveni, P. Jayakumar.
Management of a vertical maxillary excess in an adult
patient by combined orthodontics and orthognathic
surgery- a case report. J Ind Orthod Soc 2007;41:7-16.
4. Yuh-Jia Hsieh, Ellen Wen-Ching Ko, Yu-Fang Liao,
Chiung-Shing Huang. Correction of Severe Class II
Division 1 malocclusion with Miniscrew Anchorage-
A case report. J. Taiwan Assoc. Orthod. 2013;25:31-
45.
5. Makoto Nishimura, Minayo Sannohe, Hiroshi
Nagasaka, Kaoru Igarashi, Junji Sugawara.Non
Extraction treatment with temporary skeletal
anchorage devices to correct a Class II Division 2
malocclusion with excessive gingival display.
American Journal of Orthodontics and Dentofacial
Orthopedics. 2014; Volume 145, Issue 1, Pages 85-94.
6. GiampetroFarronato et al. Post-Surgical Orthodontic
Treatment Planning: A case report with 20 year follow
up. J Oral Maxillofac Res. 2011;2: e4.
How to cite this article: Shetty A, Basu P, Bhaskar B, Nayak USK.
Creating smiles- the holistic way!! – orthodontic surgical
correction of bimaxillary protrusion. J Dent Specialities, 2015;3(2):211-216.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
_________________________________________________________________________Case Report
J Dent Specialities.2015;3(2):217-219 217
Bonded ceramic inlays or full coverage crowns? – a review and case
report
Anuya Patankar1, Ramandeep Kaur Sandhu2, Raman Sandhu3, Mohit Kheur4
ABSTRACT
The esthetic demands of the patient have to be combined with conservative
treatment procedures to deliver functional restorations for endodontically treated
teeth. Ceramic inlays, fabricated in lithium dislicate material, satisfy both these
requirements as post-endodontic restorations.
This paper demonstrates a simple, esthetic and conservative alternative to full
coverage crowns for the restoration of endodontically treated teeth.
Keywords: Esthetic, Ceramic, Inlay
INTRODUCTION
ignificant loss of the tooth structure is a common
clinical problem following dental caries and
endodontic treatment. This compromises the
structural integrity of the tooth and increases its
chances of fracture. Traditionally, a full coverage
restoration is used to restore a tooth functionally and
esthetically. However, a full coverage crown has
been known to lead to secondary caries and fracture
of the underlying tooth.1 Over the last few years due
to increased esthetic demands and the need for
conservative procedures, there is an increased interest
in all ceramic inlays for the restoration of
endodontically treated teeth.2
In the past, inlays were used for restoration of
mutilated and carious teeth. The materials commonly
used were base metal alloys and gold alloys. The
wedging effect and the unesthetic appearance of the
metal inlays and the high cost of the gold alloys led
to the emergence of all ceramic inlays as the material
of choice. The advantages of ceramic inlays are their
high esthetic value and the ability to bond to the
teeth.3,4,5
IPS Empress II system (IVOCLAR VIVADENT,
SCHAAN, LIECHTENSTEIN) introduced to the
world of dentistry in the early nineties was previously
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DOI: 10.5958/2393-9834.2015.00019.4
used for the fabrication of ceramic inlays. However
studies have shown that this material has limited
physical properties and flexural strength6. IPS
E.MAX material (IVOCLAR VIVADENT,
SCHAAN, LIECHTENSTEIN) which is made up of
lithium disilicate glass ceramic and supplemented
with a universally applicable nano-fluorapatite glass-
ceramic to veneer all the IPS E.MAX system
components is now being used in place of IPS
Empress II ceramic material as a common all-ceramic
material.7
This article describes a case report of the use of a
ceramic inlay instead of a full coverage crown to
restore the function of an endodontically treated
tooth.
CASE REPORT
A 23 year old female patient was referred to the
department of Prosthodontics at M.A. Rangoonwala
Dental College and Research Centre from the
Department of Conservative Dentistry and
Endodontics for post endodontic restoration of the
maxillary left second premolar tooth. (Fig: 1) The
clinical examination of the tooth showed that there
were intact facial, lingual and mesial walls following
endodontic treatment. The distal wall of the tooth was
missing due to caries. The tooth had a short clinical
height. The patient desired an esthetic restoration and
it was decided to place a ceramic inlay instead of a
porcelain fused to metal crown to restore the tooth
keeping in mind the short clinical crown height and
the esthetic demands of the patient.
The tooth preparation for the ceramic inlay was
performed using diamond burs. (DIA-BURS, MANI,
INDIA) as per the protocol mentioned by Swift et al.8
(Fig: 2) Care was taken so that the preparation was as
1,2,3Post Graduate Student, 4Professor,
Department of Prosthodontics, M. A. Rangoonwala College of Dental
Sciences and Research Centre, Pune,
India
Address for Correspondence
Anuya Patankar Post Graduate Student,
Department of Prosthodontics, M. A.
Rangoonwala College of Dental Sciences and Research Centre, Pune,
India
Received: 24-10-2014
Accepted: 26-03-2015
S
Bonded ceramic inlays or full coverage crowns? a review and case report ____________________Patankar A et al.
J Dent Specialities.2015;3(2):217-219 218
conservative as possible and an intact enamel border
was available at the cervical floor of the preparation.
The final impression of the tooth preparation was
made using addition silicone material. (3M
EXPRESSTM VPS IMPRESSION MATERIAL, 3M
ESPE, USA)
The final restoration was fabricated in IPS E.MAX
lithium disilicate material (IVOCLAR VIVADENT,
SCHAAN, LIECHTENSTEIN). (Fig: 3) The
restoration was checked for fit and accuracy. It was
etched with hydrofluoric acid (IVOCLAR
VIVADENT, SCHAAN, LIECHTENSTEIN) for 20
seconds and a silane coupling agent (RelyXTM
Ceramic Primer, 3M ESPE, USA) was applied.
The final restoration was bonded to the tooth using
RelyXTM U200 cement (3M ESPE, USA). (Fig: 4)
The occlusion was adjusted and it was polished using
diamond burs, polishing disks and strips. The
restoration was examined and scored according to the
modified United States Public Health Service
(USPHS) criteria of Ryge.9
The authors have successfully treated numerous
patients using this conservative protocol and are
awaiting results of a clinical trial.
Fig-1: Pre treatment presentation
Fig-2: Tooth preparation
Fig-3: Lithium disilicate inlay on model
Fig-4: Bonded inlay in situ
DISCUSSION
Determination of the optimum type of post
endodontic restoration depends on the residual tooth
structure and the functional requirements of the
tooth.10 With recent advances in adhesive systems,
the concept of minimal intervention dentistry has
been introduced to preserve sound tooth structure.
Adhesive restorations have higher ability to transmit
and distribute functional stresses through the bonding
interface to the tooth which helps to reinforce the
remaining tooth.11
A ceramic inlay may be preferred over porcelain
fused to metal crown due to various reasons,
primarily due to the conservative tooth preparation
required for fabricating the inlay. A second critical
reason is esthetics. In porcelain fused to metal
crowns, the grey colour of the metal substructure has
to be masked by placing a layer of opaque ceramic
material. Ceramic inlays are fabricated from
translucent ceramic materials and therefore have
better esthetic properties. A dark line along the
Figure 9
Bonded ceramic inlays or full coverage crowns? a review and case report ____________________Patankar A et al.
J Dent Specialities.2015;3(2):217-219 219
gingival margin, compromised periodontal health are
more likely to be seen in porcelain fused to metal
crowns as compared to the use of ceramic inlays.1,12,13
Chipping/delamination of the veneering ceramic seen
in porcelain fused to metal restorations is frequently a
clinical complication which is eliminated by the use
of lithium disilicate restorations.14
Gupta et al have shown that ceramic inlays are viable
alternatives to full coverage crowns.15 Other in-vitro
studies have shown that that all ceramic inlays placed
in posterior teeth provide a highly successful esthetic
restoration.16,17
A limited number of studies have been carried out
using IPS Empress II system (IVOCLAR
VIVADENT, SCHAAN, LIECHTENSTEIN) as the
core material for the fabrication of ceramic inlays.18,19
However, there is no literature on the use of modern
lithium disilicate inlays to assess their clinical
performance. The authors are presently carrying out a
clinical trial on the same and the results are
promising.
The literature also does not report on how much tooth
structure must be destroyed to decide between an
inlay and a full coverage crown as the post
endodontic restoration. Clinical trials are needed to
determine the extent of destruction that warrants a
crown and not a partial coverage restoration.
CONCLUSION
Ceramic inlays have many advantages as compared
to porcelain fused to metal crowns for restoration of
endodontically treated teeth and should be considered
for the same in cases where tooth destruction may not
warrant the use of an endodontic post or full coverage
crown.
DISCLAIMER
The authors state that there is no financial interest of
any from in any product or company mentioned in
the article.
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complications and short-term failures of zirconia
single crowns and partial fixed dental prostheses. J
Prosthet Dent. 2014;112:778-83
2. Garlapati R, Venigalla BS, Kamishetty S, Thumu J.
Ceramic onlay for endodontically treated mandibular
molar. J Orofac Sci 2014;6:69-72.
3. Keller A, Fazekas A. Metal-based esthetic inlays.
Fogorv Sz. 1995;88:283-87.
4. Roberson T, Heymann H, Swift E. Sturdevant’s Art
and Science of Operative Dentistry. 4th edition. St.
Louis, Missouri. 2002. Page 802.
5. Christensen GJ. Tooth-colored inlays and onlays. J Am
Dent Assoc. 1988;117:12E-17E
6. Toksavul S, Toman M. A short-term clinical
evaluation of IPS Empress 2 crowns. Int J Prosthodont.
2007;20:168-72.
7. Etman M, Woolford M. Three-year clinical evaluation
of two ceramic crown systems: A preliminary study J
Prosthet Dent 2010;103:80-90
8. Roberson T, Heymann H, Swift E. Sturdevant’s Art
and Science of Operative Dentistry. 4th edition. St.
Louis, Missouri Elsevier, 2002. Page 580-582.
9. Ryge G. Clinical criteria. Int Dent J 1980;30:347–358
10. Sarabi N, Taji H, Jalayer J, Ghaffari N, Forghani M.
Fracture resistance and failure mode of endodontically
treated premolars restored with different adhesive
restorations. J Dent Mater Tech 2015;4:13-20.
11. Ozyoney G, Yanıkog˘lu F, Tag˘tekin D, Hayran O.
The Efficacy of Glass-Ceramic Onlays in the
Restoration of Morphologically Compromised and
Endodontically Treated Molars. Int J Prosthodont
2013;26:230–34.
12. Anusavice. Philip’s Science of Dental Materials, 11th
edition, St. Louis, Missouri Elsevier; 2008, page 671.
13. Behr M, Zeman F, Baitinger T, Galler J, Koller M,
Handel G, Rosentritt M. The clinical performance of
porcelain-fused-to-metal precious alloy single crowns:
chipping, recurrent caries, periodontitis, and loss of
retention. Int J Prosthodont. 2014;27:153-60.
14. Fasbinder DJ, Dennison JB, Heys D, Neiva G. A
clinical evaluation of chairside lithium disilicate
CAD/CAM crowns: a two-year report. J Am Dent
Assoc. 2010;141:10S-4S.
15. Gupta A, Musani S, Dugal R, Jain R, Railkar B,
Mootha A. A comparison of fracture resistance of
endodontically treated teeth restored with bonded
partial restorations and full-coverage porcelain-fused-
to-metal crowns. Int J Periodontics Restorative
Dent. 2014;34:405-11
16. Beier US, Kapferer I, Burtscher D, Geisinger JM,
Dumfahrt H. Clinical performance of all-ceramic inlay
and onlay restorations in posterior teeth. Int J
prosthodont 2012;25:395-02.
17. Schaefer O, Kuepper H, Sigusch BW, Kuepper H,
Guentsh A. Three-dimensional fit of lithium disilicate
partial crowns in vitro. J Dent. 2013;41:271-7.
18. Murgueitio R, Bernal G. Three-year clinical follow-up
of posterior teeth restored with leucite-reinforced IPS
empress onlays and partial veneer crowns. Journal of
prosthodontics 2012;21:340-45.
19. Tagtekin DA, Ozyöney G, Yanikoglu F. Two-
year clinical evaluation of IPS Empress
II ceramic onlays/inlays. Oper Dent. 2009 ;34:369-78.
How to cite this article: Patankar A, Sandhu RK, Sandhu R, Kheur
M. Bonded ceramic inlays or full coverage crowns? – a review and case report. J Dent Specialities, 2015;3(2):217-219.
Source of Support: NIL
Conflict of Interest: All authors report no conflict of interest
related to this study.
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